Healthcare Provider Details

I. General information

NPI: 1649285263
Provider Name (Legal Business Name): GRANDIN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 GRANDIN RD SW
ROANOKE VA
24015-2315
US

IV. Provider business mailing address

1327 GRANDIN RD SW
ROANOKE VA
24015-2315
US

V. Phone/Fax

Practice location:
  • Phone: 540-777-3403
  • Fax: 540-777-3406
Mailing address:
  • Phone: 540-777-3403
  • Fax: 540-777-3406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number0201004016
License Number StateVA

VIII. Authorized Official

Name: MR. CHARLES WEST
Title or Position: OWNER
Credential: RPH
Phone: 540-774-5500