Provider Demographics
NPI:1760884233
Name:WINNERSVILLE PHARMACY, LLC
Entity Type:Organization
Organization Name:WINNERSVILLE PHARMACY, LLC
Other - Org Name:AMERIMED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-253-0067
Mailing Address - Street 1:PO BOX 4824
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-4824
Mailing Address - Country:US
Mailing Address - Phone:229-253-0067
Mailing Address - Fax:229-219-1588
Practice Address - Street 1:3782 OLD US HIGHWAY 41 N
Practice Address - Street 2:SUITE C
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6834
Practice Address - Country:US
Practice Address - Phone:229-253-0067
Practice Address - Fax:229-219-1588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0100623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148299OtherPK