Provider Demographics
NPI:1154512903
Name:SACK, GREGORY WILLIAM
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:SACK
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 1:12647 OLIVE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6345
Mailing Address - Country:US
Mailing Address - Phone:800-325-3982
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6345
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03315816183500000X
MI5302022110183500000X
AZ11834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist