Healthcare Provider Details

I. General information

NPI: 1841450442
Provider Name (Legal Business Name): GRAND MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3137 S GRAND BLVD
SAINT LOUIS MO
63118-1020
US

IV. Provider business mailing address

3137 S GRAND BLVD
SAINT LOUIS MO
63118-1020
US

V. Phone/Fax

Practice location:
  • Phone: 314-865-1528
  • Fax: 314-865-5219
Mailing address:
  • Phone: 314-865-1528
  • Fax: 314-865-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2008019033
License Number StateMO

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000