Provider Demographics
NPI:1568529964
Name:LARGE, GREGORY (BS PHARM, RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:LARGE
Suffix:
Gender:M
Credentials:BS PHARM, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0777
Mailing Address - Country:US
Mailing Address - Phone:276-523-1713
Mailing Address - Fax:276-523-2931
Practice Address - Street 1:14 E 27TH ST N
Practice Address - Street 2:SUITE 1
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3624
Practice Address - Country:US
Practice Address - Phone:276-523-1713
Practice Address - Fax:276-523-2931
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist