Healthcare Provider Details

I. General information

NPI: 1548262132
Provider Name (Legal Business Name): GORE GREEN COUNTRY DRUG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N MAIN ST
GORE OK
74435-0330
US

IV. Provider business mailing address

PO BOX 330
GORE OK
74435-0330
US

V. Phone/Fax

Practice location:
  • Phone: 918-489-5558
  • Fax: 918-489-5359
Mailing address:
  • Phone: 918-489-5558
  • Fax: 918-489-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number34-5226
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRIS CRUMPLER
Title or Position: OWNER
Credential:
Phone: 918-489-5558