Provider Demographics
NPI:1619025715
Name:GATEWAY PHARMACY INC.
Entity Type:Organization
Organization Name:GATEWAY PHARMACY INC.
Other - Org Name:GATEWAY PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALSAMARAE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-835-9999
Mailing Address - Street 1:15690 JOY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228
Mailing Address - Country:US
Mailing Address - Phone:313-835-9999
Mailing Address - Fax:313-835-6539
Practice Address - Street 1:15690 JOY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228
Practice Address - Country:US
Practice Address - Phone:313-835-9999
Practice Address - Fax:313-835-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010073603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2362488Medicaid