Provider Demographics
NPI:1518021864
Name:IMDORF, GREGORY JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOSEPH
Last Name:IMDORF
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 1:3935 W ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3012
Mailing Address - Country:US
Mailing Address - Phone:480-627-0605
Mailing Address - Fax:
Practice Address - Street 1:9501 E SHEA BLVD # MC093
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6719
Practice Address - Country:US
Practice Address - Phone:480-627-0605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12203OtherSTATE PHARMACIST LICENSE