Provider Demographics
NPI:1689910457
Name:ULMER, GREGORY MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MARK
Last Name:ULMER
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 1:48 HIGHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8615
Mailing Address - Country:US
Mailing Address - Phone:540-966-3832
Mailing Address - Fax:
Practice Address - Street 1:48 HIGHFIELD LN
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-8615
Practice Address - Country:US
Practice Address - Phone:540-966-3832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-22
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009677183500000X
WVRP0005157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist