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General NPI Number Information
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NPI Number | 1083906077
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Entity Type | Individual
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Provider Name | CHARLES CARLON GRUBB
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Gender | Male
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Dates
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Enumeration Date | 05/09/2011
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Last Update Date | 05/09/2011
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Provider Practice Location Address
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Address Line | 94 MONTAUK HWY UNIT A
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City | EAST MORICHES
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State | NY
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Zip | 11940-1156
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Country | US
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Telephone | 631-874-3784
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 625
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City | BRIDGEHAMPTON
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State | NY
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Zip | 11932-0625
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 025901
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License Number State | NY
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