1770055923 NPI number — GOSNELL DRUGS 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 1770055923 NPI number — GOSNELL DRUGS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOSNELL DRUGS 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:
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:
1770055923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 BEVILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSNELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-751-9242
Provider Business Mailing Address Fax Number:
870-751-9291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 BEVILL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSNELL
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-559-5525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
TYSON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-751-9242

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 234926407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600073809 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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