Healthcare Provider Details

I. General information

NPI: 1861457004
Provider Name (Legal Business Name): THE MEDICINE CABINET OF WAYCROSS DOWNTOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 TEBEAU ST
WAYCROSS GA
31501-4728
US

IV. Provider business mailing address

620 TEBEAU ST
WAYCROSS GA
31501-4728
US

V. Phone/Fax

Practice location:
  • Phone: 912-283-2772
  • Fax: 912-284-0009
Mailing address:
  • Phone: 912-283-2772
  • Fax: 912-284-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE005927
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JON MEEKS
Title or Position: OWNER
Credential:
Phone: 912-383-8510