1518058288 NPI number — GATLINS PHARMACY INC

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 1518058288 NPI number — GATLINS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATLINS PHARMACY INC
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:
GATLINS PHARMACY
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:
1518058288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TISHOMINGO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38873-0369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-438-6605
Provider Business Mailing Address Fax Number:
662-438-6680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 FIRST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TISHOMINGO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38873-8441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-438-6605
Provider Business Practice Location Address Fax Number:
662-438-6680
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DORAN
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-438-6605

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 00799011 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00039276 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2043431 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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