Healthcare Provider Details

I. General information

NPI: 1023652179
Provider Name (Legal Business Name): GATEWAY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 YUKON DR UNIT 5
BISMARCK ND
58503-9777
US

IV. Provider business mailing address

PO BOX 994
BISMARCK ND
58502-0994
US

V. Phone/Fax

Practice location:
  • Phone: 701-354-7591
  • Fax:
Mailing address:
  • Phone: 701-354-7591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3505332
Identifier TypeOTHER
Identifier StateND
Identifier IssuerNCPDP
# 2
Identifier1479620
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: STACEY CHRIST
Title or Position: DIRECTOR OF COMPOUNDING
Credential: PHARMD
Phone: 701-354-7591