Healthcare Provider Details

I. General information

NPI: 1255705349
Provider Name (Legal Business Name): GRANE SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MIDDLETOWN RD
LIMA PA
19063
US

IV. Provider business mailing address

105 GAMMA DRIVE SUITE 100
PITTSBURGH PA
15238
US

V. Phone/Fax

Practice location:
  • Phone: 610-891-5783
  • Fax: 610-891-5860
Mailing address:
  • Phone: 412-449-0680
  • Fax: 129-685-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPP482618
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPP482618
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBOARD OF PHARMACY
# 2
Identifier1008270470004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. ROBERT CHARLES FUNDERLICH
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 412-449-0690