Provider Demographics
NPI:1710479597
Name:GREGG, AMBER D
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:D
Last Name:GREGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1548
Mailing Address - Country:US
Mailing Address - Phone:952-442-4407
Mailing Address - Fax:952-442-5787
Practice Address - Street 1:851 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1548
Practice Address - Country:US
Practice Address - Phone:952-442-4407
Practice Address - Fax:952-442-5787
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN118324OtherBOARD OF PHARMACY