Provider Demographics
NPI:1295018422
Name:SEROCKI, GREGORY JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:SEROCKI
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 1:3189 S WOODSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-4146
Mailing Address - Country:US
Mailing Address - Phone:417-880-0574
Mailing Address - Fax:
Practice Address - Street 1:3189 S WOODSTOCK AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-4146
Practice Address - Country:US
Practice Address - Phone:417-880-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001489681835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy