Provider Demographics
NPI:1548226434
Name:OKEFENOKEE PHARMACY OF WAYCROSS, LLC DBA BATTEN'S PRESCRIPTION SHOPPE
Entity Type:Organization
Organization Name:OKEFENOKEE PHARMACY OF WAYCROSS, LLC DBA BATTEN'S PRESCRIPTION SHOPPE
Other - Org Name:GUARDIAN PHARMACY OF WAYCROSS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE MANAGER / CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-283-1646
Mailing Address - Street 1:1401 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4528
Mailing Address - Country:US
Mailing Address - Phone:912-283-1646
Mailing Address - Fax:912-283-5383
Practice Address - Street 1:1401 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4528
Practice Address - Country:US
Practice Address - Phone:912-283-1646
Practice Address - Fax:912-283-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0060293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00219051AMedicaid
1124318OtherNCPDP
GA00219051AMedicaid