Provider Demographics
NPI:1063790020
Name:MACK, GREGORY SCOTT
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:SCOTT
Last Name:MACK
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 1:101 SAINT ANDREWS LN
Mailing Address - Street 2:PHARMACY DEPT GLEN COVE HOSPITAL
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2254
Mailing Address - Country:US
Mailing Address - Phone:516-674-7778
Mailing Address - Fax:516-674-7952
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:PHARMACY DEPT GLEN COVE HOSPITAL
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2254
Practice Address - Country:US
Practice Address - Phone:516-674-7778
Practice Address - Fax:516-674-7952
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist