Healthcare Provider Details

I. General information

NPI: 1114087541
Provider Name (Legal Business Name): JERRY WHITE'S PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 HIGHWAY 17
TOCCOA GA
30577-8275
US

IV. Provider business mailing address

3741 HIGHWAY 17
TOCCOA GA
30577-8275
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-2662
  • Fax: 706-886-2867
Mailing address:
  • Phone: 706-886-2662
  • Fax: 706-886-2867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE007089
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier00403686A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. J ERRY WHITE
Title or Position: PRESIDENT
Credential: PAHRMACIST
Phone: 706-886-2662