Provider Demographics
NPI:1013788439
Name:OKEFENOKEE PHARMACY OF WAYCROSS, LLC
Entity Type:Organization
Organization Name:OKEFENOKEE PHARMACY OF WAYCROSS, LLC
Other - Org Name:GUARDIAN PHARMACY OF WAYCROSS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE MANAGER/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-283-1646
Mailing Address - Street 1:1401 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4528
Mailing Address - Country:US
Mailing Address - Phone:912-283-1646
Mailing Address - Fax:912-283-5383
Practice Address - Street 1:1401 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4528
Practice Address - Country:US
Practice Address - Phone:912-283-1646
Practice Address - Fax:912-283-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010869OtherGEORGIA BOARD OF PHARMACY
GA000219051AMedicaid