Provider Demographics
NPI:1790332906
Name:OCILLA PHARMACY, INC.
Entity Type:Organization
Organization Name:OCILLA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-468-5929
Mailing Address - Street 1:515 N IRWIN AVE
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-5007
Mailing Address - Country:US
Mailing Address - Phone:229-468-5929
Mailing Address - Fax:229-468-7313
Practice Address - Street 1:515 N IRWIN AVE
Practice Address - Street 2:
Practice Address - City:OCILLA
Practice Address - State:GA
Practice Address - Zip Code:31774-5007
Practice Address - Country:US
Practice Address - Phone:229-468-5929
Practice Address - Fax:229-468-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00032744AMedicaid