Provider Demographics
NPI:1609181304
Name:KING, GREGORY MARK (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:KING
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 1:501 WATER ST
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-1146
Mailing Address - Country:US
Mailing Address - Phone:440-286-4167
Mailing Address - Fax:440-285-3141
Practice Address - Street 1:501 WATER ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1146
Practice Address - Country:US
Practice Address - Phone:440-286-4167
Practice Address - Fax:440-285-3141
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03217651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist