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General NPI Number Information
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NPI Number | 1861889990
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Entity Type | Individual
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Provider Name | MELODIE GRADY PHARMD
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Gender | Female
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Dates
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Enumeration Date | 04/15/2015
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Last Update Date | 04/22/2022
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Provider Practice Location Address
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Address Line | 2132 W PULLMAN RD
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City | MOSCOW
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State | ID
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Zip | 83843-4011
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Country | US
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Telephone | 208-997-5082
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Fax | 208-207-2917
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Provider Business Mailing Address
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Address Line | 1143 BEAR CREEK RD
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City | PRINCETON
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State | ID
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Zip | 83857-9753
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Country | US
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Telephone | 208-874-2176
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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 | E17480
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P7306
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License Number State | ID
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