Provider Demographics
NPI:1245213701
Name:BLANK, GREGORY F (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:F
Last Name:BLANK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2343
Mailing Address - Country:US
Mailing Address - Phone:859-261-1313
Mailing Address - Fax:859-655-3042
Practice Address - Street 1:272 PIKE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-2343
Practice Address - Country:US
Practice Address - Phone:859-261-1313
Practice Address - Fax:859-655-3042
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP00358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54005012Medicaid