Provider Demographics
NPI:1053413450
Name:WIREGRASS DRUGS INC
Entity type:Organization
Organization Name:WIREGRASS DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLIGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-435-4571
Mailing Address - Street 1:PO BOX 72188
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-2188
Mailing Address - Country:US
Mailing Address - Phone:229-435-4571
Mailing Address - Fax:229-878-4926
Practice Address - Street 1:430 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ASHFORD
Practice Address - State:AL
Practice Address - Zip Code:36312-0367
Practice Address - Country:US
Practice Address - Phone:334-899-3100
Practice Address - Fax:334-899-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL1101903336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000054812Medicaid
1991430OtherPK
0373920001Medicare PIN