Provider Demographics
NPI:1851951651
Name:MAAG, GREG A (BSPHARM)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:MAAG
Suffix:
Gender:M
Credentials:BSPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0115
Mailing Address - Country:US
Mailing Address - Phone:208-233-2063
Mailing Address - Fax:208-233-6158
Practice Address - Street 1:333 W CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3243
Practice Address - Country:US
Practice Address - Phone:208-233-2063
Practice Address - Fax:208-233-6158
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist