Provider Demographics
NPI:1205107778
Name:MUDD, GREGORY D
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:MUDD
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 1:7900 GANNON AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 N MCKNIGHT RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-4911
Practice Address - Country:US
Practice Address - Phone:314-991-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-15
Last Update Date:2012-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29144183500000X
CARPH30847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist