Provider Demographics
NPI:1972893006
Name:GW PHARMACY LLC
Entity Type:Organization
Organization Name:GW PHARMACY LLC
Other - Org Name:GW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYMON
Authorized Official - Middle Name:
Authorized Official - Last Name:TIGRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-573-7788
Mailing Address - Street 1:201 N COLLEGE ST
Mailing Address - Street 2:SUITE 101 BOX 9
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-4437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N COLLEGE ST STE 101
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-4439
Practice Address - Country:US
Practice Address - Phone:601-825-2897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS08886/02.63336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2588284OtherNCPDP PROVIDER IDENTIFICATION NUMBER