Provider Demographics
NPI:1205836814
Name:GORDON DRUG STORE INC
Entity Type:Organization
Organization Name:GORDON DRUG STORE INC
Other - Org Name:GORDONS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKPARET
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-477-6773
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-1180
Mailing Address - Country:US
Mailing Address - Phone:337-477-6773
Mailing Address - Fax:337-477-7126
Practice Address - Street 1:2716 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8216
Practice Address - Country:US
Practice Address - Phone:337-477-6773
Practice Address - Fax:337-477-7126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.000427-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2028780OtherPK