Provider Demographics
NPI:1790093102
Name:WOODYS LONGBRANCH PHARMACY INC
Entity Type:Organization
Organization Name:WOODYS LONGBRANCH PHARMACY INC
Other - Org Name:WOODY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-316-3031
Mailing Address - Street 1:WOODY'S LONGBRANCH PHARMACY
Mailing Address - Street 2:P.O. BOX 309
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533
Mailing Address - Country:US
Mailing Address - Phone:706-867-9493
Mailing Address - Fax:706-867-9495
Practice Address - Street 1:130 LONG BRANCH RD
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-7132
Practice Address - Country:US
Practice Address - Phone:706-867-9493
Practice Address - Fax:706-867-9495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1160340OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA6475060001Medicare NSC