Healthcare Provider Details

I. General information

NPI: 1750452942
Provider Name (Legal Business Name): JOHN JOSEPH GRUBER RPH, CGP, FASCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8615 GOSHEN RD
EDWARDSVILLE IL
62025-6913
US

IV. Provider business mailing address

8615 GOSHEN RD
EDWARDSVILLE IL
62025-6913
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-3348
  • Fax:
Mailing address:
  • Phone: 618-656-3348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: