Healthcare Provider Details

I. General information

NPI: 1831189679
Provider Name (Legal Business Name): GATEWAY DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3997 MEETING ST
LORIS SC
29569-3053
US

IV. Provider business mailing address

3997 MEETING ST
LORIS SC
29569-3053
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-5134
  • Fax: 843-756-0689
Mailing address:
  • Phone: 843-756-5134
  • Fax: 843-756-0689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number50-000971
License Number StateSC

VIII. Authorized Official

Name: MR. THOMAS FREDDIE MOORE
Title or Position: PRESIDENT
Credential: RPH.
Phone: 843-756-5134