Provider Demographics
NPI:1508113705
Name:GREGORY, BRANDON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 ASH ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-3445
Mailing Address - Country:US
Mailing Address - Phone:417-855-0428
Mailing Address - Fax:
Practice Address - Street 1:857 E MAIN ST
Practice Address - Street 2:STE 3
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-1500
Practice Address - Country:US
Practice Address - Phone:417-855-0428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012023175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600092646Medicaid
MO2012023175OtherSTATE BOARD OF PHARMACY