Provider Demographics
NPI:1275559130
Name:GASTON MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:GASTON MEMORIAL HOSPITAL, INC
Other - Org Name:GASTON MEMORIAL HOSPITAL - PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-834-2239
Mailing Address - Street 1:2525 COURT DR
Mailing Address - Street 2:P.O. BOX 1747
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2140
Mailing Address - Country:US
Mailing Address - Phone:704-834-2155
Mailing Address - Fax:
Practice Address - Street 1:2525 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-834-2758
Practice Address - Fax:704-834-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01191333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3406407OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0365379Medicaid
NC3400032Medicaid
340032Medicare ID - Type Unspecified