Provider Demographics
NPI:1487930962
Name:CISZEWSKI, GREG THOMAS (DPH)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:THOMAS
Last Name:CISZEWSKI
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 N. HALL RD
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2538
Mailing Address - Country:US
Mailing Address - Phone:865-982-2463
Mailing Address - Fax:865-982-5331
Practice Address - Street 1:227 N. HALL RD
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2538
Practice Address - Country:US
Practice Address - Phone:865-982-2463
Practice Address - Fax:865-982-5331
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist