Provider Demographics
NPI:1205982352
Name:WAUKA MOUNTAIN PHARMACY INC
Entity type:Organization
Organization Name:WAUKA MOUNTAIN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHWETA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODSMALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-983-9556
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-0410
Mailing Address - Country:US
Mailing Address - Phone:770-983-9556
Mailing Address - Fax:770-983-9580
Practice Address - Street 1:5233 CLEVELAND HWY
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:GA
Practice Address - Zip Code:30527-2205
Practice Address - Country:US
Practice Address - Phone:770-983-9556
Practice Address - Fax:770-983-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0069143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00362865AMedicaid
2015525OtherPK
2015525OtherPK