Provider Demographics
NPI:1912951294
Name:DECRESCENZO, GREGORY MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:DECRESCENZO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WATERWAY LN
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-3879
Mailing Address - Country:US
Mailing Address - Phone:772-567-2555
Mailing Address - Fax:772-567-0013
Practice Address - Street 1:3721 10TH CT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6559
Practice Address - Country:US
Practice Address - Phone:772-567-2555
Practice Address - Fax:772-567-0013
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0435990001Medicare ID - Type UnspecifiedPHARMACY MEDICARE #