Basic Information
Provider Information | |||||||||
NPI: | 1497261051 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORREALE | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMACIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14TH MEDICAL GROUP, 201 INDEPENDENCE DRIVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS AFB | ||||||||
State: | MS | ||||||||
PostalCode: | 39710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6624342273 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 201 INDEPENDENCE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | MS | ||||||||
PostalCode: | 397105300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6624342273 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2017 | ||||||||
LastUpdateDate: | 09/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PCT.0014056 | CT | Y |   | Pharmacy Service Providers | Pharmacist |   |
ID Information
ID | Type | State | Issuer | Description | PCT.0014056 | 01 | CT | PHARMACIST LICENSE | OTHER |