Provider Demographics
NPI:1841201266
Name:WOODBINE MEDICAL, LLC
Entity Type:Organization
Organization Name:WOODBINE MEDICAL, LLC
Other - Org Name:WOODBINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER / CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-464-7186
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:GA
Mailing Address - Zip Code:31569-0729
Mailing Address - Country:US
Mailing Address - Phone:912-576-6998
Mailing Address - Fax:912-729-7275
Practice Address - Street 1:908 GEORGIA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-3574
Practice Address - Country:US
Practice Address - Phone:912-576-6998
Practice Address - Fax:912-729-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0088003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126185OtherPK
GA000032568CMedicaid