Provider Demographics
NPI:1134720006
Name:PETROSKY, GREGORY WILLIAM
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:PETROSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:WILLIAM
Other - Last Name:PETROSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1018 GIRNDT LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-4974
Mailing Address - Country:US
Mailing Address - Phone:979-732-0415
Mailing Address - Fax:
Practice Address - Street 1:2103 MILAM ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3013
Practice Address - Country:US
Practice Address - Phone:979-732-8319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist