Provider Demographics
NPI:1548262132
Name:GORE GREEN COUNTRY DRUG, INC.
Entity type:Organization
Organization Name:GORE GREEN COUNTRY DRUG, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-489-5558
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:GORE
Mailing Address - State:OK
Mailing Address - Zip Code:74435-0330
Mailing Address - Country:US
Mailing Address - Phone:918-489-5558
Mailing Address - Fax:918-489-5359
Practice Address - Street 1:305 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GORE
Practice Address - State:OK
Practice Address - Zip Code:74435-0330
Practice Address - Country:US
Practice Address - Phone:918-489-5558
Practice Address - Fax:918-489-5359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
OK34-52263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234940AMedicaid
2073565OtherPK