Provider Demographics
NPI:1588017099
Name:METTERNICH, GREGORY JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JAMES
Last Name:METTERNICH
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 1:10320 DEER CREEK DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8451
Mailing Address - Country:US
Mailing Address - Phone:616-319-7102
Mailing Address - Fax:
Practice Address - Street 1:10320 DEER CREEK DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8451
Practice Address - Country:US
Practice Address - Phone:616-319-7102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist