=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669201711
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK HILPERT GRISETTI RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2024
-----------------------------------------------------
Last Update Date | 07/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 346
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15522-0346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-623-5512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 786 LOVELY RD
-----------------------------------------------------
City | ALUM BANK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15521-9046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-276-3377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP003563L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------