Provider Demographics
NPI:1336184514
Name:DOGWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:DOGWOOD PHARMACY LLC
Other - Org Name:DOGWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRES PIC
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-686-2620
Mailing Address - Street 1:501 N DAVIS STREET
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639
Mailing Address - Country:US
Mailing Address - Phone:229-316-8200
Mailing Address - Fax:229-686-2687
Practice Address - Street 1:501 N DAVIS ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-1426
Practice Address - Country:US
Practice Address - Phone:229-316-8200
Practice Address - Fax:229-686-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0090353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016291OtherPK
GA899038148AMedicaid
5787730001Medicare NSC