Provider Demographics
NPI:1679817688
Name:MAINELLA, GREGORY VINCENT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:VINCENT
Last Name:MAINELLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-3201
Mailing Address - Country:US
Mailing Address - Phone:774-214-4255
Mailing Address - Fax:508-841-8100
Practice Address - Street 1:731 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3201
Practice Address - Country:US
Practice Address - Phone:774-214-4255
Practice Address - Fax:508-841-8100
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
183374OtherNEBP E-PROFILE ID #
MAPH233411OtherPHARMACIST LICENSE #