Individual
GREGORY JACKSON AYCOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CAA
Contact information
Practice address
615 S NEW BALLAS RD DEPT OF, SAINT LOUIS, MO 63141-8221
(636) 386-9224
Mailing address
339 CONSORT DR, BALLWIN, MO 63011-4439
(636) 386-9224
(636) 386-7679
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
17641
NC
183500000X
Pharmacist
PS40328
FL
367H00000X
Anesthesiologist Assistant
75000176A
IN
367H00000X
Anesthesiologist Assistant
Primary
PENDING
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1103727700
ANTHEM PTAN
IN
Enumeration date
10/03/2005
Last updated
11/21/2024
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