Provider Demographics
NPI:1235142530
Name:MILLER, GREGORY K
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:MILLER
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 1:18089 D A LEDOUX RD
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-8228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 POINTE AUX LOUPE
Practice Address - Street 2:
Practice Address - City:IOTA
Practice Address - State:LA
Practice Address - Zip Code:70543
Practice Address - Country:US
Practice Address - Phone:337-779-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist