Provider Demographics
NPI:1710022207
Name:SKIDAWAY VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:SKIDAWAY VILLAGE PHARMACY INC
Other - Org Name:VILLAGE WALK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-598-8669
Mailing Address - Street 1:1 SKIDAWAY VILLAGE WALK
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31411-2908
Mailing Address - Country:US
Mailing Address - Phone:912-598-8669
Mailing Address - Fax:912-598-7208
Practice Address - Street 1:1 SKIDAWAY VILLAGE WALK
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31411-2908
Practice Address - Country:US
Practice Address - Phone:912-598-8669
Practice Address - Fax:912-598-7208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008485333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895485AMedicaid
1133533OtherNCPDP
GAPHRE008485OtherPHARMACY LICENSE
GA000895485AMedicaid
GAFLU374Medicare PIN