Provider Demographics
NPI:1669561346
Name:GATEWAY CSB PHARMACY
Entity type:Organization
Organization Name:GATEWAY CSB PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-303-1602
Mailing Address - Street 1:1915 EISENHOWER DR
Mailing Address - Street 2:BLDG 3
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-5027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1915 EISENHOWER DR
Practice Address - Street 2:BLDG 3
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-5027
Practice Address - Country:US
Practice Address - Phone:912-351-9343
Practice Address - Fax:912-351-6437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0060003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144980OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA00864729AMedicaid