MEDICARE: WAUKA MOUNTAIN PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHRE006914	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2015525	OTHER		PK

General Provider Information

NPI Number	:	1205982352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAUKA MOUNTAIN PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 410
Second Line	:
City	:	CLERMONT
State	:	GA
Zip	:	30527-0410
Country	:	US
Telephone Number	:	770-983-9556
Fax Number	:	770-983-9580

Provider Business Practice Location Address
First Line	:	5233 CLEVELAND HWY
Second Line	:
City	:	CLERMONT
State	:	GA
Zip	:	30527-2205
Country	:	US
Telephone Number	:	770-983-9556
Fax Number	:	770-983-9580

Authorized Official
Title or Position	:	OWNER / PHARMACIST
Name	:	SHWETA WOODSMALL
Credential	:	PHARMD
Telephone Number	:	770-983-9556

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	06/18/2019

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