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General NPI Number Information
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NPI Number | 1205878501
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Entity Type | Organization
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Legal Business Name | GRANITE PHARMACY INC.
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Dates
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Enumeration Date | 06/12/2006
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Last Update Date | 10/26/2013
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Provider Practice Location Address
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Address Line | 576 BALLARD RD STE 2
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City | MILTON
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State | VT
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Zip | 05468-4210
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Country | US
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Telephone | 802-527-9930
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Fax | 802-527-9764
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Provider Business Mailing Address
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Address Line | 576 BALLARD RD STE 2 PO BOX 2094
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City | MILTON
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State | VT
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Zip | 05468-4210
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Country | US
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Telephone | 802-527-9930
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Fax | 802-527-9764
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Authorized Official
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Title or Position | PRESIDENT
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Name | LISA DOCKHAM
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Credential | RPH.
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Telephone | 802-527-9930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 141-0003297
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License Number State | VT
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