MEDICARE: GORE GREEN COUNTRY DRUG, 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	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy	34-5226	OK

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
2	2073565	OTHER		PK

General Provider Information

NPI Number	:	1548262132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORE GREEN COUNTRY DRUG, INC.

Provider Business Mailing Address
First Line	:	PO BOX 330
Second Line	:
City	:	GORE
State	:	OK
Zip	:	74435-0330
Country	:	US
Telephone Number	:	918-489-5558
Fax Number	:	918-489-5359

Provider Business Practice Location Address
First Line	:	305 N MAIN ST
Second Line	:
City	:	GORE
State	:	OK
Zip	:	74435-0330
Country	:	US
Telephone Number	:	918-489-5558
Fax Number	:	918-489-5359

Authorized Official
Title or Position	:	OWNER
Name	:	CHRIS CRUMPLER
Credential	:
Telephone Number	:	918-489-5558

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	08/12/2021

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