=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205649969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRX HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2025
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 LINCOLN WAY
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-232-1653
-----------------------------------------------------
Fax | 515-232-3382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 LINCOLN WAY
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-232-1653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL FULLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-321-7644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------