Healthcare Provider Details

I. General information

NPI: 1629066204
Provider Name (Legal Business Name): GATEWAY PHARMACY OF CLARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2005
Last Update Date: 10/03/2020
Certification Date: 10/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 N MCEWAN ST
CLARE MI
48617-1154
US

IV. Provider business mailing address

11271 HARRISON AVE
FARWELL MI
48622-9439
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-2900
  • Fax: 989-386-3710
Mailing address:
  • Phone: 989-339-9008
  • Fax: 855-855-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301007820
License Number StateMI

VIII. Authorized Official

Name: MR. JOHN WILLIAM GROSS
Title or Position: PRESIDENT
Credential: RPH
Phone: 989-339-9008