Provider Demographics
NPI:1023209764
Name:GATEWAY PHARMACY GROUP
Entity type:Organization
Organization Name:GATEWAY PHARMACY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST - OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:859-289-8501
Mailing Address - Street 1:102 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-1190
Mailing Address - Country:US
Mailing Address - Phone:859-289-8501
Mailing Address - Fax:859-289-8004
Practice Address - Street 1:102 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-1190
Practice Address - Country:US
Practice Address - Phone:859-289-8501
Practice Address - Fax:859-289-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO6785332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90008624Medicaid
KY90008624Medicaid