MEDICARE: GLN INC OF DURANT

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	274660	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2074870	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558348755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLN INC OF DURANT

Provider Business Mailing Address
First Line	:	PO BOX 426
Second Line	:	#3
City	:	CHECOTAH
State	:	OK
Zip	:	74426-0426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1231 N WASHINGTON AVE
Second Line	:
City	:	DURANT
State	:	OK
Zip	:	74701-2119
Country	:	US
Telephone Number	:	580-924-2903
Fax Number	:	580-924-7337

Authorized Official
Title or Position	:	PRES/OWNER
Name	:	GARY NICHOLS
Credential	:
Telephone Number	:	580-924-2903

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	11/18/2014

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