Provider Demographics
NPI:1033195862
Name:HINES, GREG S
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:S
Last Name:HINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 HIGHWAY 185
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-9691
Mailing Address - Country:US
Mailing Address - Phone:270-842-4341
Mailing Address - Fax:270-842-7893
Practice Address - Street 1:1340 HIGHWAY 185
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-9691
Practice Address - Country:US
Practice Address - Phone:270-842-4341
Practice Address - Fax:270-842-7893
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54030176Medicaid
KY54030176Medicaid