Provider Demographics
NPI:1386249084
Name:GRESHAM, ROLAND GREGORY
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:GREGORY
Last Name:GRESHAM
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 1:4460 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3649
Mailing Address - Country:US
Mailing Address - Phone:501-428-4007
Mailing Address - Fax:
Practice Address - Street 1:12700 CHENAL PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3360
Practice Address - Country:US
Practice Address - Phone:501-707-1996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty