Provider Demographics
NPI:1205057270
Name:SCHUTRUM, GREGORY (RPH)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SCHUTRUM
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 1:1400 COUNTY ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-2297
Mailing Address - Country:US
Mailing Address - Phone:607-739-2087
Mailing Address - Fax:
Practice Address - Street 1:209 MOUNT ZOAR ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-1231
Practice Address - Country:US
Practice Address - Phone:607-733-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00352089Medicaid