Provider Demographics
NPI:1548337686
Name:WINN-DIXIE PHARMACY #482
Entity type:Organization
Organization Name:WINN-DIXIE PHARMACY #482
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:REG PHARMACIST
Authorized Official - Phone:706-562-8330
Mailing Address - Street 1:1100 HUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907
Mailing Address - Country:US
Mailing Address - Phone:706-562-8330
Mailing Address - Fax:706-562-0463
Practice Address - Street 1:1100 HUNT AVENUE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907
Practice Address - Country:US
Practice Address - Phone:706-562-8330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0077733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA044611OtherBUSINESS LICENSE
GA007773OtherCERTIFICATE OF OCCUPANCY