Provider Demographics
NPI:1437646403
Name:GATEWAY WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:GATEWAY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NCPDP COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-590-0808
Mailing Address - Street 1:200 RITTENHOUSE CIRCLE
Mailing Address - Street 2:EAST BUILDING STE 5
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007
Mailing Address - Country:US
Mailing Address - Phone:888-590-0808
Mailing Address - Fax:866-740-4689
Practice Address - Street 1:3433 AGLER RD.
Practice Address - Street 2:STE 1100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219
Practice Address - Country:US
Practice Address - Phone:888-590-0808
Practice Address - Fax:866-740-4689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRJ170641332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site