Provider Demographics
NPI:1710044508
Name:GORDON SMITH PHARMACY
Entity Type:Organization
Organization Name:GORDON SMITH PHARMACY
Other - Org Name:THE DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NAGEM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH CCN
Authorized Official - Phone:318-428-3212
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-1515
Mailing Address - Country:US
Mailing Address - Phone:318-428-3212
Mailing Address - Fax:318-428-7755
Practice Address - Street 1:212 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-1515
Practice Address - Country:US
Practice Address - Phone:318-428-3212
Practice Address - Fax:318-428-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA428 IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1909843OtherNARP
LA123949Medicaid