Healthcare Provider Details

I. General information

NPI: 1154512903
Provider Name (Legal Business Name): GREGORY WILLIAM SACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD STE 200
SAINT LOUIS MO
63141-6345
US

IV. Provider business mailing address

12647 OLIVE BLVD STE 200
SAINT LOUIS MO
63141-6345
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax:
Mailing address:
  • Phone: 800-325-3982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03315816
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302022110
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11834
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: