Provider Demographics
NPI:1649564147
Name:BAISE, GREG (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:BAISE
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 1:34722 PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4052
Mailing Address - Country:US
Mailing Address - Phone:313-632-4962
Mailing Address - Fax:
Practice Address - Street 1:34722 PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4052
Practice Address - Country:US
Practice Address - Phone:313-632-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist