Healthcare Provider Details

I. General information

NPI: 1225431745
Provider Name (Legal Business Name): WINNERSVILLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3782 OLD US HIGHWAY 41 N SUITE B
VALDOSTA GA
31602-6834
US

IV. Provider business mailing address

PO BOX 4824
VALDOSTA GA
31604-4824
US

V. Phone/Fax

Practice location:
  • Phone: 229-249-0100
  • Fax: 229-253-9010
Mailing address:
  • Phone: 229-253-0067
  • Fax: 229-219-1588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010063
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TROY ALLEN
Title or Position: GENERAL MANAGER
Credential:
Phone: 229-253-0067