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General NPI Number Information
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NPI Number | 1124275383
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Entity Type | Individual
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Provider Name | THANE Z GROVER PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 08/19/2008
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Last Update Date | 12/21/2012
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Provider Practice Location Address
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Address Line | 141 N. WASHINGTON ST. BROULIM'S PHARMACY
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City | AFTON
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State | WY
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Zip | 83110
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Country | US
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Telephone | 307-885-5550
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11 883 STUMP CREEK RD
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City | AUBURN
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State | WY
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Zip | 83111-0011
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Country | US
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Telephone | 307-413-1335
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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 | P6205
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH-0012033
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 3605
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License Number State | WY
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