Provider Demographics
NPI:1205948114
Name:GATESVILLE DRUG COMPANY, LTD
Entity type:Organization
Organization Name:GATESVILLE DRUG COMPANY, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:254-865-2417
Mailing Address - Street 1:2513 S. STATE HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-2519
Mailing Address - Country:US
Mailing Address - Phone:254-865-2417
Mailing Address - Fax:254-865-4024
Practice Address - Street 1:2513 S. STATE HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-2519
Practice Address - Country:US
Practice Address - Phone:254-865-2417
Practice Address - Fax:254-865-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200993336C0003X
3336C0004X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144947Medicaid
TX149115Medicaid
4503389OtherNCPDP PROVIDER IDENTIFICATION NUMBER