Provider Demographics
NPI:1871874305
Name:PANKOW, GREG (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:PANKOW
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WILMOT ROAD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-2385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 DEMPSTER ST STE T01116
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-692-2184
Practice Address - Fax:847-692-2467
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-0353361835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist