MEDICARE: GRAND VALUE PHARMACY INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	530100439	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2043099	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699862888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND VALUE PHARMACY INC

Provider Business Mailing Address
First Line	:	10920 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2052
Country	:	US
Telephone Number	:	313-931-0010
Fax Number	:	313-934-1658

Provider Business Practice Location Address
First Line	:	10920 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2052
Country	:	US
Telephone Number	:	313-931-0010
Fax Number	:	313-934-1658

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	KEVIN WHITE
Credential	:	RPH
Telephone Number	:	313-931-0010

Provider Enumeration Date	:	10/07/2006
Last Update Date	:	10/20/2016

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Directions to “GRAND VALUE PHARMACY INC ” Practice Location

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