Provider Demographics
NPI:1093058265
Name:WILDWOOD SANITARIUM INCORPORATED
Entity Type:Organization
Organization Name:WILDWOOD SANITARIUM INCORPORATED
Other - Org Name:WILDWOOD LIFESTYLE CENTER AND HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-419-0023
Mailing Address - Street 1:435 LIFE STYLE LN
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30757-4174
Mailing Address - Country:US
Mailing Address - Phone:706-419-0023
Mailing Address - Fax:706-820-1474
Practice Address - Street 1:435 LIFE STYLE LN
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:GA
Practice Address - Zip Code:30757-4174
Practice Address - Country:US
Practice Address - Phone:706-419-0023
Practice Address - Fax:706-820-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139673OtherPK