Provider Demographics
NPI:1427020999
Name:GATEWAY PHARMACY
Entity Type:Organization
Organization Name:GATEWAY PHARMACY
Other - Org Name:GATEWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-877-5032
Mailing Address - Street 1:2044 MADISON AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4641
Mailing Address - Country:US
Mailing Address - Phone:618-877-5032
Mailing Address - Fax:618-877-0540
Practice Address - Street 1:2044 MADISON AVE
Practice Address - Street 2:STE 4
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4641
Practice Address - Country:US
Practice Address - Phone:618-877-5032
Practice Address - Fax:618-877-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540147003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1462352OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1462352OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========002Medicaid