Provider Demographics
NPI:1184718942
Name:GORDON DRUGS, INC.
Entity type:Organization
Organization Name:GORDON DRUGS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-628-2425
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0249
Mailing Address - Country:US
Mailing Address - Phone:478-628-2425
Mailing Address - Fax:478-628-2263
Practice Address - Street 1:240 MILLEDGEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031
Practice Address - Country:US
Practice Address - Phone:478-628-2425
Practice Address - Fax:478-628-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0051433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00144196AMedicaid
GA00144196BMedicaid
GA00144196AMedicaid
0131050001Medicare NSC