Provider Demographics
NPI:1912021981
Name:MICHAEL, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MICHAEL
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 1:2922 NOSTRAND AVE
Mailing Address - Street 2:APT #3F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1859
Mailing Address - Country:US
Mailing Address - Phone:718-891-2861
Mailing Address - Fax:
Practice Address - Street 1:511 BRIGHTON BEACH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6403
Practice Address - Country:US
Practice Address - Phone:718-332-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist