Provider Demographics
NPI:1679643332
Name:WOODSTOCK PHARMACEUTICAL & COMPOUNDING CENTER INC
Entity type:Organization
Organization Name:WOODSTOCK PHARMACEUTICAL & COMPOUNDING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:GRIFFIN
Authorized Official - Last Name:MARQUESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, CDE,CDM
Authorized Official - Phone:770-926-6478
Mailing Address - Street 1:8612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4829
Mailing Address - Country:US
Mailing Address - Phone:770-926-6478
Mailing Address - Fax:770-531-7557
Practice Address - Street 1:8612 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4829
Practice Address - Country:US
Practice Address - Phone:770-926-6478
Practice Address - Fax:770-531-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0076953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000178373AMedicaid
GA000178373AMedicaid