Healthcare Provider Details

I. General information

NPI: 1669045365
Provider Name (Legal Business Name): TRACI LYNN GRUBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 WRIGHT AVE
ALMA MI
48801-1134
US

IV. Provider business mailing address

1341 WRIGHT AVE
ALMA MI
48801-1134
US

V. Phone/Fax

Practice location:
  • Phone: 989-463-6111
  • Fax: 989-466-0742
Mailing address:
  • Phone: 989-463-6111
  • Fax: 989-466-0742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: