Provider Demographics
NPI:1992394142
Name:WOODY, KEVIN JOSEPH
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:WOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 439
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-0439
Mailing Address - Country:US
Mailing Address - Phone:770-983-3510
Mailing Address - Fax:770-983-7986
Practice Address - Street 1:5226 DAHLONEGA HWY
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:GA
Practice Address - Zip Code:30527-1946
Practice Address - Country:US
Practice Address - Phone:770-983-3510
Practice Address - Fax:770-983-7986
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist