Provider Demographics
NPI:1265567192
Name:GMT AND P ENTERPRISES
Entity type:Organization
Organization Name:GMT AND P ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-453-2218
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:FLIPPIN
Mailing Address - State:AR
Mailing Address - Zip Code:72634-0519
Mailing Address - Country:US
Mailing Address - Phone:870-453-2218
Mailing Address - Fax:870-453-2280
Practice Address - Street 1:109 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FLIPPIN
Practice Address - State:AR
Practice Address - Zip Code:72634-8613
Practice Address - Country:US
Practice Address - Phone:870-453-2218
Practice Address - Fax:870-453-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR098803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0409880OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR149181716Medicaid
AR149186407Medicaid
AR149186407Medicaid