Provider Demographics
NPI:1023652179
Name:GATEWAY PHARMACY, LLC
Entity type:Organization
Organization Name:GATEWAY PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPOUNDING
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRIST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-354-7591
Mailing Address - Street 1:PO BOX 994
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0994
Mailing Address - Country:US
Mailing Address - Phone:701-354-7591
Mailing Address - Fax:
Practice Address - Street 1:7300 YUKON DR UNIT 5
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-9777
Practice Address - Country:US
Practice Address - Phone:701-354-7591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-01
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3505332OtherNCPDP
ND1479620Medicaid