Provider Demographics
NPI:1528444197
Name:GREGORIO, SEBASTIAN NED (RPH)
Entity type:Individual
Prefix:MR
First Name:SEBASTIAN
Middle Name:NED
Last Name:GREGORIO
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 1:2163 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4218
Mailing Address - Country:US
Mailing Address - Phone:208-724-8937
Mailing Address - Fax:210-757-7820
Practice Address - Street 1:2163 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4218
Practice Address - Country:US
Practice Address - Phone:208-724-8937
Practice Address - Fax:210-757-7820
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011562183500000X
IDP4856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP4856OtherPHARMACIST LICENSE
OR0011562OtherPHARMACIST LICENSE