Provider Demographics
NPI:1700874278
Name:GASSAWAY DRUG COMPANY
Entity Type:Organization
Organization Name:GASSAWAY DRUG COMPANY
Other - Org Name:CARL WALKERS DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-364-5193
Mailing Address - Street 1:620 ELK ST
Mailing Address - Street 2:
Mailing Address - City:GASSAWAY
Mailing Address - State:WV
Mailing Address - Zip Code:26624-1136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 ELK ST
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-1136
Practice Address - Country:US
Practice Address - Phone:304-364-5193
Practice Address - Fax:304-364-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05508483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5002100OtherOTHER ID NUMBER
WV8884830801Medicaid
5002100OtherOTHER ID NUMBER