Provider Demographics
NPI:1245985928
Name:PORET, GREGORY RUSSELL (BS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:RUSSELL
Last Name:PORET
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-0127
Mailing Address - Country:US
Mailing Address - Phone:318-876-2104
Mailing Address - Fax:
Practice Address - Street 1:1007 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3403
Practice Address - Country:US
Practice Address - Phone:318-876-2104
Practice Address - Fax:318-876-3964
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10986183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist