Provider Demographics
NPI:1447670377
Name:GREGO, RENE' ANTOINETTE
Entity type:Individual
Prefix:
First Name:RENE'
Middle Name:ANTOINETTE
Last Name:GREGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENE'
Other - Middle Name:ANTOINETTE
Other - Last Name:LAMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:550 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2904
Mailing Address - Country:US
Mailing Address - Phone:843-281-8309
Mailing Address - Fax:843-281-8440
Practice Address - Street 1:550 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2904
Practice Address - Country:US
Practice Address - Phone:843-281-8309
Practice Address - Fax:843-281-8440
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC011023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist