Provider Demographics
NPI:1992705339
Name:RANDY'S GATEWAY DRUG, INC
Entity type:Organization
Organization Name:RANDY'S GATEWAY DRUG, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-964-2494
Mailing Address - Street 1:3118 CEDAR VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-3075
Mailing Address - Country:US
Mailing Address - Phone:276-964-2494
Mailing Address - Fax:276-963-2920
Practice Address - Street 1:3118 CEDAR VALLEY DR
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-3075
Practice Address - Country:US
Practice Address - Phone:276-964-2494
Practice Address - Fax:276-963-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003219183500000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8505756Medicaid