Provider Demographics
NPI:1063927010
Name:GANT PHARMACY SERVICES INC
Entity type:Organization
Organization Name:GANT PHARMACY SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-256-2274
Mailing Address - Street 1:805 N KENTUCKY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2045
Mailing Address - Country:US
Mailing Address - Phone:417-256-2274
Mailing Address - Fax:417-256-1036
Practice Address - Street 1:805 N KENTUCKY AVE STE 2
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2045
Practice Address - Country:US
Practice Address - Phone:417-256-2274
Practice Address - Fax:417-256-1036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GANT PHARMACY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600305510Medicaid