Provider Demographics
NPI:1184711152
Name:MANLEY, GREGORY KEITH (RPH)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:KEITH
Last Name:MANLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 NEEDHAM RD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:AL
Mailing Address - Zip Code:36915-3001
Mailing Address - Country:US
Mailing Address - Phone:205-673-2820
Mailing Address - Fax:
Practice Address - Street 1:604 E PUSHMATAHA ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:AL
Practice Address - Zip Code:36904-2620
Practice Address - Country:US
Practice Address - Phone:205-459-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10377183500000X
MSE-07032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-07032OtherMS PHARMACIST LICENSE
AL10377OtherPHARMACIST LICENSE