Provider Demographics
NPI:1508313800
Name:DOUBLE SPRINGS PHARMACY LLC
Entity Type:Organization
Organization Name:DOUBLE SPRINGS PHARMACY LLC
Other - Org Name:GATEWAY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-489-2572
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:SLOCOMB
Mailing Address - State:AL
Mailing Address - Zip Code:36375-0279
Mailing Address - Country:US
Mailing Address - Phone:334-886-2442
Mailing Address - Fax:334-886-7442
Practice Address - Street 1:26289 HIGHWAY 195
Practice Address - Street 2:
Practice Address - City:DOUBLE SPRINGS
Practice Address - State:AL
Practice Address - Zip Code:35553-2554
Practice Address - Country:US
Practice Address - Phone:205-489-2572
Practice Address - Fax:205-489-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1146573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL192145Medicaid
2164140OtherPK