MEDICARE: GREGORY JAMES MCKETTRICK RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14565	NC

General Provider Information

NPI Number	:	1386978369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY JAMES MCKETTRICK RPH

Provider Business Mailing Address
First Line	:	951 DAVIE AVE
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-5301
Country	:	US
Telephone Number	:	704-873-6216
Fax Number	:	704-873-9279

Provider Business Practice Location Address
First Line	:	951 DAVIE AVE
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-5301
Country	:	US
Telephone Number	:	704-873-6216
Fax Number	:	704-873-9279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	09/24/2009

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