Healthcare Provider Details

I. General information

NPI: 1245580919
Provider Name (Legal Business Name): JOHN GRIGG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57590 29 PALMS HWY
YUCCA VALLEY CA
92284-2934
US

IV. Provider business mailing address

57590 29 PALMS HWY
YUCCA VALLEY CA
92284-2934
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-0651
  • Fax: 760-365-9078
Mailing address:
  • Phone: 760-365-0651
  • Fax: 760-365-9078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number36599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: