Healthcare Provider Details

I. General information

NPI: 1013053842
Provider Name (Legal Business Name): GDR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MERCER STREET
TCHULA MS
39169
US

IV. Provider business mailing address

PO BOX 217
TCHULA MS
39169-0217
US

V. Phone/Fax

Practice location:
  • Phone: 662-235-4422
  • Fax: 662-235-4301
Mailing address:
  • Phone: 662-235-4422
  • Fax: 662-235-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number01455
License Number StateMS

VIII. Authorized Official

Name: GLENN DANIEL ROBERTS
Title or Position: PRESIDENT
Credential: RPH
Phone: 662-235-4422