Provider Demographics
NPI:1831393107
Name:MAYO CLINIC HEALTH SYSTEM IN WAYCROSS
Entity type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM IN WAYCROSS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-287-2506
Mailing Address - Street 1:1900 TEBEAU STREET
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5246
Mailing Address - Country:US
Mailing Address - Phone:912-287-2640
Mailing Address - Fax:
Practice Address - Street 1:1900 TEBEAU STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5246
Practice Address - Country:US
Practice Address - Phone:912-287-2640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0059143336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA108000306OtherMEDCO
GA1155476OtherNCPDP
GAPHRE005914OtherPHARMACY LICENSE
GAPHRE005914OtherPHARMACY LICENSE