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General NPI Number Information
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NPI Number | 1184260713
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Entity Type | Individual
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Provider Name | TATIANA VASILIEVNA GRAHAM PHARMACIST
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Gender | Female
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Dates
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Enumeration Date | 11/19/2019
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Last Update Date | 12/21/2022
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Provider Practice Location Address
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Address Line | 901 JOHNSON ST
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City | ELKHART
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State | IN
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Zip | 46514-3329
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Country | US
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Telephone | 574-264-5996
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Fax |
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Provider Business Mailing Address
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Address Line | 71210 INDIANA LAKE DR
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City | UNION
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State | MI
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Zip | 49130
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Country | US
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Telephone | 574-265-9640
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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 | 26023521A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 26023521A
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License Number State | IN
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