Provider Demographics
NPI:1700276219
Name:UNERTL, GREGORY
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:UNERTL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GREGORY
Other - Middle Name:CARL
Other - Last Name:UNERTL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1116 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2818
Mailing Address - Country:US
Mailing Address - Phone:920-323-6311
Mailing Address - Fax:
Practice Address - Street 1:3300 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5426
Practice Address - Country:US
Practice Address - Phone:920-682-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10402-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist