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General NPI Number Information
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NPI Number | 1871668020
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Entity Type | Individual
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Provider Name | JERRY VANCE GRIMMITT RPH
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Gender | Male
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Dates
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Enumeration Date | 11/22/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 785 CHICKAMAUGA AV LONGLEY PHARMACY
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City | ROSSVILLE
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State | GA
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Zip | 30741
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Country | US
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Telephone | 706-866-1220
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Fax | 706-861-7505
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Provider Business Mailing Address
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Address Line | 2196 GOURGE RD
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City | HENAGAR
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State | AL
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Zip | 35978
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Country | US
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Telephone | 256-657-3462
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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 | 507
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 20271
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 9494
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License Number State | AL
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