Provider Demographics
NPI:1851933097
Name:PERRY, GREGORY A
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33786 ECR 1610
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:OK
Practice Address - Zip Code:74872-7487
Practice Address - Country:US
Practice Address - Phone:580-759-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist