Healthcare Provider Details

I. General information

NPI: 1013968023
Provider Name (Legal Business Name): GRANVILLE MEDICAL PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 N BROADWAY ST
CHICAGO IL
60660-1903
US

IV. Provider business mailing address

6212 N BROADWAY ST
CHICAGO IL
60660-1903
US

V. Phone/Fax

Practice location:
  • Phone: 773-274-5888
  • Fax: 773-274-5961
Mailing address:
  • Phone: 773-274-5888
  • Fax: 773-274-5961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT S. JOSEPH
Title or Position: PRESIDENT/PHARMACIST
Credential: RPH.
Phone: 847-729-9034