Provider Demographics
NPI:1114969342
Name:VIDALIA PHARMACY INC
Entity Type:Organization
Organization Name:VIDALIA PHARMACY INC
Other - Org Name:VIDALIA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDINGFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-4134
Mailing Address - Street 1:209 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4713
Mailing Address - Country:US
Mailing Address - Phone:912-537-4134
Mailing Address - Fax:912-537-4169
Practice Address - Street 1:209 JACKSON ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4713
Practice Address - Country:US
Practice Address - Phone:912-537-4134
Practice Address - Fax:912-537-4169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336I0012X, 3336L0003X, 3336M0003X
GA0050323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012881OtherPK
GA0037749AMedicaid
1160310001Medicare PIN