Provider Demographics
NPI:1942391560
Name:SCALLON, GREGORY L
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:L
Last Name:SCALLON
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 1:619 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4600
Mailing Address - Country:US
Mailing Address - Phone:985-626-5660
Mailing Address - Fax:985-626-5748
Practice Address - Street 1:619 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-4600
Practice Address - Country:US
Practice Address - Phone:985-626-5660
Practice Address - Fax:985-626-5748
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist