Provider Demographics
NPI:1114087541
Name:JERRY WHITE'S PHARMACY, INC
Entity Type:Organization
Organization Name:JERRY WHITE'S PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J ERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PAHRMACIST
Authorized Official - Phone:706-886-2662
Mailing Address - Street 1:3741 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-8275
Mailing Address - Country:US
Mailing Address - Phone:706-886-2662
Mailing Address - Fax:706-886-2867
Practice Address - Street 1:3741 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-8275
Practice Address - Country:US
Practice Address - Phone:706-886-2662
Practice Address - Fax:706-886-2867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0070893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00403686AMedicaid
GABJ1959115OtherDEA NUMBER