Provider Demographics
NPI:1700154366
Name:INNOVATIVE MEDS RX
Entity Type:Organization
Organization Name:INNOVATIVE MEDS RX
Other - Org Name:GATES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-475-8706
Mailing Address - Street 1:364 N SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3532
Mailing Address - Country:US
Mailing Address - Phone:336-789-5050
Mailing Address - Fax:336-786-7169
Practice Address - Street 1:364 N SOUTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3532
Practice Address - Country:US
Practice Address - Phone:336-789-5050
Practice Address - Fax:336-786-7169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 261QM2500X
NC111903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3459953OtherNCPDP PROVIDER IDENTIFICATION NUMBER