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General NPI Number Information
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NPI Number | 1710044508
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Entity Type | Organization
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Legal Business Name | GORDON SMITH PHARMACY
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 212 MAIN STREET
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City | OAK GROVE
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State | LA
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Zip | 71263-1515
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Country | US
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Telephone | 318-428-3212
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Fax | 318-428-7755
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Provider Business Mailing Address
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Address Line | PO BOX 1515
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City | OAK GROVE
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State | LA
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Zip | 71263-1515
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Country | US
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Telephone | 318-428-3212
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Fax | 318-428-7755
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE
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Name | DAVID WAYNE NAGEM
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Credential | RPH CCN
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Telephone | 318-428-3212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 428 IR
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License Number State | LA
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