Provider Demographics
NPI:1861457004
Name:THE MEDICINE CABINET OF WAYCROSS DOWNTOWN LLC
Entity Type:Organization
Organization Name:THE MEDICINE CABINET OF WAYCROSS DOWNTOWN LLC
Other - Org Name:THE MEDICINE CABINET OF WAYCROSS - DOWNTOWN, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-383-8510
Mailing Address - Street 1:620 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4728
Mailing Address - Country:US
Mailing Address - Phone:912-283-2772
Mailing Address - Fax:912-284-0009
Practice Address - Street 1:620 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4728
Practice Address - Country:US
Practice Address - Phone:912-283-2772
Practice Address - Fax:912-284-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0059273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012895OtherPK
GA00507064AMedicaid