Provider Demographics
NPI:1912995515
Name:GREGORY DRUG
Entity Type:Organization
Organization Name:GREGORY DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREVIOUS OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:WIK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-835-8198
Mailing Address - Street 1:604 MAIN
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:SD
Mailing Address - Zip Code:57533
Mailing Address - Country:US
Mailing Address - Phone:605-835-8198
Mailing Address - Fax:605-835-8827
Practice Address - Street 1:604 MAIN
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:SD
Practice Address - Zip Code:57533
Practice Address - Country:US
Practice Address - Phone:605-835-8198
Practice Address - Fax:605-835-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-09
Last Update Date:2009-06-11
Deactivation Date:2008-07-09
Deactivation Code:
Reactivation Date:2008-11-26
Provider Licenses
StateLicense IDTaxonomies
SD1000505333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8500032Medicaid
SD8500032Medicaid
NE=========00Medicaid
0497060001Medicare NSC