Healthcare Provider Details

I. General information

NPI: 1891851168
Provider Name (Legal Business Name): GWA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 FRISCO AVE
CLINTON OK
73601-3322
US

IV. Provider business mailing address

815 FRISCO AVE
CLINTON OK
73601-3322
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-1244
  • Fax: 580-323-0455
Mailing address:
  • Phone: 580-323-1244
  • Fax: 580-323-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28-5048
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREG ADAMS
Title or Position: OWNER
Credential: DPH
Phone: 580-323-1244