Provider Demographics
NPI:1649372186
Name:SPAKE, GREGORY (RPH CPH)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:SPAKE
Suffix:
Gender:M
Credentials:RPH CPH
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 156
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32923-0156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:321-449-0585
Practice Address - Street 1:4020 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2472
Practice Address - Country:US
Practice Address - Phone:321-254-7803
Practice Address - Fax:321-449-0585
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25626183500000X
FLPU5073183500000X
AZ9383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist