Provider Demographics
NPI:1629363197
Name:MISSE, GREG (RPH)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:MISSE
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 1:15345 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1074
Mailing Address - Country:US
Mailing Address - Phone:913-393-4420
Mailing Address - Fax:913-393-4420
Practice Address - Street 1:15345 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1074
Practice Address - Country:US
Practice Address - Phone:913-393-4420
Practice Address - Fax:913-393-4420
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist