1205927571 NPI number — GATEWAY PHARMACY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205927571 NPI number — GATEWAY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GATEWAY PHARMACY SOUTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205927571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 994
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BISMARCK
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58502-0994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-223-1656
Provider Business Mailing Address Fax Number:
701-223-9628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
BISMARCK
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58504-5477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-223-1656
Provider Business Practice Location Address Fax Number:
701-223-9628
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AURIT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-224-9521

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 90 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3503679 . This is a "NCPDP NUMBER" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1455415 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: N711223 . This is a "MEDICARE IMMUNIZATIONS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 8533860 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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