Provider Demographics
NPI:1992250120
Name:SOUTH, GREGORY (PHARM D)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:SOUTH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:SOUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARM D
Mailing Address - Street 1:617 WOODDUCK DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2672
Mailing Address - Country:US
Mailing Address - Phone:801-201-5510
Mailing Address - Fax:
Practice Address - Street 1:4700 YELM HWY SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-4986
Practice Address - Country:US
Practice Address - Phone:360-438-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60669668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60669668OtherWASHINTON STATE DEPARTMENT OF HEALTH