Provider Demographics
NPI:1710209549
Name:LOPEZ, GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LOPEZ
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 1:2441 VESTAL PKWY E
Mailing Address - Street 2:SAMS CLUB PHARMACY
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2018
Mailing Address - Country:US
Mailing Address - Phone:607-797-1370
Mailing Address - Fax:
Practice Address - Street 1:2441 VESTAL PKWY E
Practice Address - Street 2:SAMS CLUB PHARMACY
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2018
Practice Address - Country:US
Practice Address - Phone:607-797-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045657183500000X
PARP045696R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist