Healthcare Provider Details

I. General information

NPI: 1629338223
Provider Name (Legal Business Name): WIREGRASS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W. MAPLE AVE PHARMACY DEPT.
GENEVA AL
36340
US

IV. Provider business mailing address

1200 W. MAPLE AVE PHARMACY DEPT.
GENEVA AL
36340
US

V. Phone/Fax

Practice location:
  • Phone: 334-684-3655
  • Fax: 334-684-1294
Mailing address:
  • Phone: 334-684-3655
  • Fax: 334-684-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE MICHAEL CLEVELAND
Title or Position: PHARMACY DIRECTOR
Credential: RPH.
Phone: 334-684-3655