Provider Demographics
NPI:1972815157
Name:EADY, GREGG
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:EADY
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 1:502 10TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-4004
Mailing Address - Country:US
Mailing Address - Phone:607-341-2210
Mailing Address - Fax:
Practice Address - Street 1:1395 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3505
Practice Address - Country:US
Practice Address - Phone:336-651-2910
Practice Address - Fax:336-651-2907
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0975424Medicaid