Provider Demographics
NPI:1275510208
Name:GATEWAY PRESCRIPTION CENTER, INC
Entity Type:Organization
Organization Name:GATEWAY PRESCRIPTION CENTER, INC
Other - Org Name:BAYA PHARMACY WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:386-719-9952
Mailing Address - Street 1:1465 W US HIGHWAY 90
Mailing Address - Street 2:SUITE #110
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-6123
Mailing Address - Country:US
Mailing Address - Phone:386-755-2233
Mailing Address - Fax:386-752-6721
Practice Address - Street 1:1465 W US HIGHWAY 90
Practice Address - Street 2:SUITE #110
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-6123
Practice Address - Country:US
Practice Address - Phone:386-755-2233
Practice Address - Fax:386-752-6721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY PRESCRIPTION CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-30
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
FLPH8820333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100014400Medicaid
FLPH8820OtherPHARMACY LICENSE
4538770001Medicare NSC