Provider Demographics
NPI:1467007419
Name:CARROLL, GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CARROLL
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 1:29700 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-4609
Mailing Address - Country:US
Mailing Address - Phone:440-944-2801
Mailing Address - Fax:440-944-8713
Practice Address - Street 1:29700 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4609
Practice Address - Country:US
Practice Address - Phone:440-944-2801
Practice Address - Fax:440-944-8713
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03321920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist