MEDICARE: GATEWAY PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	054014700	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1462352	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1427020999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY PHARMACY

Provider Business Mailing Address
First Line	:	2044 MADISON AVE
Second Line	:	STE 4
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4641
Country	:	US
Telephone Number	:	618-877-5032
Fax Number	:	618-877-0540

Provider Business Practice Location Address
First Line	:	2044 MADISON AVE
Second Line	:	STE 4
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4641
Country	:	US
Telephone Number	:	618-877-5032
Fax Number	:	618-877-0540

Authorized Official
Title or Position	:	REGISTERED PHARMACIST
Name	:	PAMELA DEAN
Credential	:	RPH
Telephone Number	:	618-877-5032

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	10/18/2010

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Directions to “GATEWAY PHARMACY ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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