Healthcare Provider Details

I. General information

NPI: 1841201266
Provider Name (Legal Business Name): WOODBINE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 GEORGIA AVE SUITE 1
WOODBINE GA
31569-3574
US

IV. Provider business mailing address

PO BOX 729
WOODBINE GA
31569-0729
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-6998
  • Fax: 912-729-7275
Mailing address:
  • Phone: 912-576-6998
  • Fax: 912-729-7275

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 NumberPHRE008800
License Number StateGA

VIII. Authorized Official

Name: RYAN CLEMENTS
Title or Position: MEMBER / CEO
Credential: PHARM.D.
Phone: 912-464-7186