Provider Demographics
NPI:1386111672
Name:FISK, GREGORY PARKER
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:PARKER
Last Name:FISK
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 1:14030 SW 74TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-3131
Mailing Address - Country:US
Mailing Address - Phone:305-216-7492
Mailing Address - Fax:
Practice Address - Street 1:14030 SW 74 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183
Practice Address - Country:US
Practice Address - Phone:305-385-9039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist