Provider Demographics
NPI:1962584193
Name:GATEWAY COMMUNITY SVC BOARD
Entity type:Organization
Organization Name:GATEWAY COMMUNITY SVC BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-790-6220
Mailing Address - Street 1:800 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4813
Mailing Address - Country:US
Mailing Address - Phone:912-790-6220
Mailing Address - Fax:912-349-4328
Practice Address - Street 1:800 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4813
Practice Address - Country:US
Practice Address - Phone:912-790-6220
Practice Address - Fax:912-349-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0003X
GAPHRE0060003336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144980OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA00864729AMedicaid