=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851798532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MEDICINE CABINET - WARD STREET, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2014
-----------------------------------------------------
Last Update Date | 03/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 WARD ST W
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31533-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-383-6337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 ASHLEY ST W
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31533-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-383-6337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JON SCOTT MEEKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-383-0634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE010091
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------