Healthcare Provider Details

I. General information

NPI: 1861218471
Provider Name (Legal Business Name): MOLLY MARIE GRASBERGER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

IV. Provider business mailing address

2030 ARDMORE AVE APT 118
FORT WAYNE IN
46802-4861
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-3400
  • Fax:
Mailing address:
  • Phone: 260-348-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number1835P1200X
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number1835P1200X
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code1835I0206X
TaxonomyInfectious Diseases Pharmacist
License Number26026993A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: