Provider Demographics
NPI:1750657391
Name:GST PHARMACY LLC
Entity Type:Organization
Organization Name:GST PHARMACY LLC
Other - Org Name:JORDAN'S DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-704-5335
Mailing Address - Street 1:13205 DEXTER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3328
Mailing Address - Country:US
Mailing Address - Phone:313-931-3301
Mailing Address - Fax:313-931-3304
Practice Address - Street 1:13205 DEXTER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3328
Practice Address - Country:US
Practice Address - Phone:313-931-3301
Practice Address - Fax:313-931-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010097733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2376691OtherNCPDP PROVIDER IDENTIFICATION NUMBER