Provider Demographics
NPI:1093314866
Name:CARTER, GREGORY AARON
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:AARON
Last Name:CARTER
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 1:707 BRIGHAM DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2327 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-528-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP70821835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist