=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912995515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY DRUG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2005
-----------------------------------------------------
Last Update Date | 06/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 MAIN
-----------------------------------------------------
City | GREGORY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-835-8198
-----------------------------------------------------
Fax | 605-835-8827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 MAIN
-----------------------------------------------------
City | GREGORY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-835-8198
-----------------------------------------------------
Fax | 605-835-8827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PREVIOUS OWNER/PHARMACIST
-----------------------------------------------------
Name | MR. ROBERT DUANE WIK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 605-835-8198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 1000505
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------