Healthcare Provider Details

I. General information

NPI: 1295058410
Provider Name (Legal Business Name): JENNIFER GRANT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 EAST MAIN STREET
GOUVERNEUR NY
13642
US

IV. Provider business mailing address

147 CHURCH STREET
HERMON NY
13652
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-5002
  • Fax: 180-089-8423
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number20 046773
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: