MEDICARE: NICHOLAS GRINDER RPH, PHARMD

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	03127286	OH

General Provider Information

NPI Number	:	1760777148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS GRINDER RPH, PHARMD

Provider Business Mailing Address
First Line	:	6189 CARTAGE AVE NW
Second Line	:
City	:	CANAL FULTON
State	:	OH
Zip	:	44614-8219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1980 LINCOLN WAY E
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44646-6965
Country	:	US
Telephone Number	:	330-833-4151
Fax Number	:	330-833-4151

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

Provider Enumeration Date	:	06/14/2011
Last Update Date	:	06/14/2011

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