Provider Demographics
NPI:1447364419
Name:GWL INC
Entity type:Organization
Organization Name:GWL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:MABRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-423-2094
Mailing Address - Street 1:1006 W TRIMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-4618
Mailing Address - Country:US
Mailing Address - Phone:870-423-2094
Mailing Address - Fax:870-423-4302
Practice Address - Street 1:1006 W TRIMBLE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4618
Practice Address - Country:US
Practice Address - Phone:870-423-2094
Practice Address - Fax:870-423-4302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR08092333600000X, 3336C0003X
3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149376OtherPK
AR100626407Medicaid
MOEC601489701Medicaid
0461690001Medicare NSC