Healthcare Provider Details

I. General information

NPI: 1548389117
Provider Name (Legal Business Name): GAS CITY DISTRIBUTORS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E MAIN ST
GAS CITY IN
46933-1621
US

IV. Provider business mailing address

PO BOX 128
GAS CITY IN
46933-0128
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-6976
  • Fax: 765-674-0114
Mailing address:
  • Phone: 765-674-6976
  • Fax: 765-674-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60004362A
License Number StateIN

VIII. Authorized Official

Name: TERRY CHENEY
Title or Position: PRESIDENT,AO
Credential: RPH
Phone: 765-674-6976