Provider Demographics
NPI:1912091323
Name:CCC MEDICAL INC
Entity Type:Organization
Organization Name:CCC MEDICAL INC
Other - Org Name:WOODWARD'S EXPRESS CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEYWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-483-6811
Mailing Address - Street 1:2280 SALEM RD SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2003
Mailing Address - Country:US
Mailing Address - Phone:770-483-6811
Mailing Address - Fax:770-483-1776
Practice Address - Street 1:2280 SALEM RD SE
Practice Address - Street 2:SUITE 103
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2003
Practice Address - Country:US
Practice Address - Phone:770-483-6811
Practice Address - Fax:770-483-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005339333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00112516BMedicaid
1108338OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA00112516AMedicaid
GA00112516AMedicaid
GA00112516AMedicaid