1992705339 NPI number — RANDYS GATEWAY DRUG

Table of content: (NPI 1992705339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992705339 NPI number — RANDYS GATEWAY DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDYS GATEWAY DRUG
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:
Provider Other Organization Name Type Code:
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:
1992705339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3118 CEDAR VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLANDS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24641-3075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-964-2494
Provider Business Mailing Address Fax Number:
276-963-2920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3118 CEDAR VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLANDS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24641-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-964-2494
Provider Business Practice Location Address Fax Number:
276-963-2920
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
YOST
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST/PRESIDENT
Authorized Official Telephone Number:
276-964-2494

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  0201003219 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8505756 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com