Healthcare Provider Details

I. General information

NPI: 1114969342
Provider Name (Legal Business Name): VIDALIA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 JACKSON ST
VIDALIA GA
30474-4713
US

IV. Provider business mailing address

209 JACKSON ST
VIDALIA GA
30474-4713
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-4134
  • Fax: 912-537-4169
Mailing address:
  • Phone: 912-537-4134
  • Fax: 912-537-4169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number005032
License Number StateGA

VIII. Authorized Official

Name: WALTER BEDINGFIELD
Title or Position: OWNER
Credential:
Phone: 912-537-4134