Healthcare Provider Details

I. General information

NPI: 1053397257
Provider Name (Legal Business Name): HAMILTON WATERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N BEACHVIEW DR
JEKYLL ISLAND GA
31527-0816
US

IV. Provider business mailing address

10 N BEACHVIEW DR P.O. BOX 13088
JEKYLL ISLAND GA
31527-0816
US

V. Phone/Fax

Practice location:
  • Phone: 912-635-2246
  • Fax: 912-635-2100
Mailing address:
  • Phone: 912-635-2246
  • Fax: 912-635-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHRE005630
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPHRE005630
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerPHARMACY LIC #
# 2
Identifier1110989
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerNABP #
# 3
Identifier00136177A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOHN R WATERS JR.
Title or Position: PHARMACIST
Credential: PHARMACIST
Phone: 912-635-2246