Provider Demographics
NPI:1669517819
Name:SELVIA, GREG ALLEN
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:ALLEN
Last Name:SELVIA
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 1:423 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1305
Mailing Address - Country:US
Mailing Address - Phone:765-653-4932
Mailing Address - Fax:
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2212
Practice Address - Country:US
Practice Address - Phone:765-655-2634
Practice Address - Fax:765-655-2636
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017344A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26017344AOtherLICENSE