NPIMap

Organization Active NPI

Wildwood Sanitarium Incorporated

Doing business as Wildwood Lifestyle Center and Hospital

  • Community/Retail Pharmacy
  • Wildwood, GA
National Provider Identifier
1093058265
Registry record updated Nov 27, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHRE009672 Issued in GA
Legal business name
WILDWOOD SANITARIUM INCORPORATED
Doing business as
Wildwood Lifestyle Center and Hospital
Practice address
435 Life Style LN
Wildwood, GA 30757-4174
Phone
(706) 419-0023
Fax
(706) 820-1474
NPI assigned
Apr 5, 2013
Last updated
Nov 27, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shelly Miller
Title
Director of Pharmacy
Phone
(706) 419-0023

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X PHRE009672 GA Primary

Addresses

Primary practice location

435 Life Style LN
Wildwood, GA 30757-4174

Mailing address

435 Life Style LN
Wildwood, GA 30757-4174
Phone (706) 419-0023

Other identifiers 1

IdentifierTypeStateIssuer
2139673OtherPK

Other names 1

  • Wildwood Lifestyle Center and Hospital Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Wildwood Lifestyle Center and Hospital3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1365120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1385510400000",
    "number": "1093058265",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "435 LIFE STYLE LN",
            "city": "WILDWOOD",
            "state": "GA",
            "postal_code": "307574174",
            "telephone_number": "706-419-0023",
            "fax_number": "706-820-1474"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "435 LIFE STYLE LN",
            "city": "WILDWOOD",
            "state": "GA",
            "postal_code": "307574174",
            "telephone_number": "706-419-0023",
            "fax_number": "706-820-1474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDWOOD SANITARIUM INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-05",
        "last_updated": "2013-11-27",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SHELLY",
        "authorized_official_title_or_position": "DIRECTOR OF PHARMACY",
        "authorized_official_telephone_number": "706-419-0023"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHRE009672",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2139673",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wildwood Lifestyle Center and Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wildwood, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.