=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366844581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTON FAMILY HEALTH SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 01/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1875 REMOUNT RD
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-874-0617
-----------------------------------------------------
Fax | 704-866-7732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1875 REMOUNT RD
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-874-0617
-----------------------------------------------------
Fax | 704-866-7732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DIRECTOR
-----------------------------------------------------
Name | MARVIN ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-322-4110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 12096
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------