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General NPI Number Information
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NPI Number | 1518675628
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Entity Type | Individual
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Provider Name | JONATHAN GRIDER PHARMD
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Gender | Male
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 11/08/2022
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Provider Practice Location Address
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Address Line | 2431 LAKEWAY DR STE C
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642-4648
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Country | US
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Telephone | 270-858-6400
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Fax | 270-866-7542
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Provider Business Mailing Address
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Address Line | PO BOX 72
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642-0072
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Country | US
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Telephone | 270-858-6400
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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 | 015051
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License Number State | KY
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