Provider Demographics
NPI:1528581402
Name:DOGWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:DOGWOOD PHARMACY LLC
Other - Org Name:DOGWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:EUGENA
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-686-2620
Mailing Address - Street 1:501 N DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639-1426
Mailing Address - Country:US
Mailing Address - Phone:229-237-1462
Mailing Address - Fax:
Practice Address - Street 1:1909 US HIGHWAY 82 W STE 11
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31793-8213
Practice Address - Country:US
Practice Address - Phone:229-256-2411
Practice Address - Fax:229-256-2488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOGWOOD PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0103673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010367OtherSTATE RETAIL PHARMACY LICENSE