Provider Demographics
NPI:1811270911
Name:SMITH, GREGORY LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:GREGORY
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:10170 MAYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9589
Mailing Address - Country:US
Mailing Address - Phone:260-486-7295
Mailing Address - Fax:260-486-9395
Practice Address - Street 1:10170 MAYSVILLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9589
Practice Address - Country:US
Practice Address - Phone:260-486-7295
Practice Address - Fax:260-486-9395
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-25
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014663A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist