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General NPI Number Information
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NPI Number | 1366901191
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Entity Type | Individual
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Provider Name | NICHOLAS MARKS GRUNEWALD PHARMD
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Gender | Male
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Dates
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Enumeration Date | 03/19/2019
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Last Update Date | 11/06/2023
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Provider Practice Location Address
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Address Line | 325 MDG, 340 MAGNOLIA CIRCLE
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City | TYNDALL AFB
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State | FL
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Zip | 32403
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Country | US
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Telephone | 850-283-7377
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Fax |
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Provider Business Mailing Address
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Address Line | 325 MDG/SGAP 340 MAGNOLIA CIR.
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City | TYNDALL AFB
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State | FL
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Zip | 32403
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Country | US
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Telephone | 850-283-7377
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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 | PD14167
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License Number State | AR
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