Provider Demographics
NPI:1497261051
Name:CORREALE, GREGORY (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CORREALE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14TH MEDICAL GROUP, 201 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39710
Mailing Address - Country:US
Mailing Address - Phone:662-434-2273
Mailing Address - Fax:
Practice Address - Street 1:201 INDEPENDENCE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-5300
Practice Address - Country:US
Practice Address - Phone:662-434-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0014056OtherPHARMACIST LICENSE