Provider Demographics
NPI:1851446454
Name:SLS PHARMACY INC
Entity Type:Organization
Organization Name:SLS PHARMACY INC
Other - Org Name:WILLACOOCHEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:STORY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-534-5195
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650-0190
Mailing Address - Country:US
Mailing Address - Phone:912-534-5195
Mailing Address - Fax:912-534-6383
Practice Address - Street 1:561 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILLACOOCHEE
Practice Address - State:GA
Practice Address - Zip Code:31650
Practice Address - Country:US
Practice Address - Phone:912-534-5195
Practice Address - Fax:912-534-6383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0065063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000022844AMedicaid
5613640001Medicare NSC