Provider Demographics
NPI:1760253561
Name:GWL INC
Entity Type:Organization
Organization Name:GWL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SPENER
Authorized Official - Last Name:MABRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-423-2094
Mailing Address - Street 1:1006 W TRIMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-4618
Mailing Address - Country:US
Mailing Address - Phone:870-423-2094
Mailing Address - Fax:870-423-4302
Practice Address - Street 1:1006 W TRIMBLE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4618
Practice Address - Country:US
Practice Address - Phone:870-423-2094
Practice Address - Fax:870-423-4302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GWL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy