Healthcare Provider Details

I. General information

NPI: 1609011816
Provider Name (Legal Business Name): BRYAN GERALD WOOD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N SAGE STREET STEWART'S DOWNTOWN DISCOUNT DRUGS
TOCCOA GA
30577
US

IV. Provider business mailing address

102 N SAGE STREET STEWARTS DOWNTOWN DISCOUNT DRUGS
TOCCOA GA
30577
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-3141
  • Fax:
Mailing address:
  • Phone: 706-886-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH017329
License Number StateGA

VII. Legacy identifiers

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

# 1
IdentifierRPH017329
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerRPH017329

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: