Provider Demographics
NPI:1447575535
Name:GREGORY, MARLENE A
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:A
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CATTARAUGUS
Mailing Address - State:NY
Mailing Address - Zip Code:14719-1015
Mailing Address - Country:US
Mailing Address - Phone:716-257-3741
Mailing Address - Fax:716-257-9586
Practice Address - Street 1:1 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CATTARAUGUS
Practice Address - State:NY
Practice Address - Zip Code:14719-1015
Practice Address - Country:US
Practice Address - Phone:716-257-3741
Practice Address - Fax:716-257-9586
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01640546Medicaid
NY1146740001Medicare PIN