Provider Demographics
NPI:1831189679
Name:GATEWAY DRUG STORE, INC.
Entity type:Organization
Organization Name:GATEWAY DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FREDDIE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-756-5134
Mailing Address - Street 1:3997 MEETING ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-3053
Mailing Address - Country:US
Mailing Address - Phone:843-756-5134
Mailing Address - Fax:843-756-0689
Practice Address - Street 1:3997 MEETING ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3053
Practice Address - Country:US
Practice Address - Phone:843-756-5134
Practice Address - Fax:843-756-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50-000971333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy