MEDICARE: GDR, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	01455	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013053842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GDR, INC

Provider Business Mailing Address
First Line	:	PO BOX 217
Second Line	:
City	:	TCHULA
State	:	MS
Zip	:	39169-0217
Country	:	US
Telephone Number	:	662-235-4422
Fax Number	:	662-235-4301

Provider Business Practice Location Address
First Line	:	112 MERCER STREET
Second Line	:
City	:	TCHULA
State	:	MS
Zip	:	39169
Country	:	US
Telephone Number	:	662-235-4422
Fax Number	:	662-235-4301

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GLENN DANIEL ROBERTS
Credential	:	RPH
Telephone Number	:	662-235-4422

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	08/22/2020

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Directions to “GDR, INC ” Practice Location

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