Provider Demographics
NPI:1649215229
Name:WYATTS PHARMACY, LLC
Entity Type:Organization
Organization Name:WYATTS PHARMACY, LLC
Other - Org Name:WYATT'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DME MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-948-8825
Mailing Address - Street 1:10671 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2062
Mailing Address - Country:US
Mailing Address - Phone:770-948-8825
Mailing Address - Fax:770-948-8848
Practice Address - Street 1:10671 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2062
Practice Address - Country:US
Practice Address - Phone:770-948-8825
Practice Address - Fax:770-948-8848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0104083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00440646AMedicaid
2012556OtherPK
GA00440646AMedicaid