Provider Demographics
NPI:1922619501
Name:GREGORISCH, JORGE LUIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:GREGORISCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-1637
Mailing Address - Country:US
Mailing Address - Phone:214-331-5466
Mailing Address - Fax:214-467-4417
Practice Address - Street 1:2323 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-1637
Practice Address - Country:US
Practice Address - Phone:214-331-5466
Practice Address - Fax:214-467-4417
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist