Provider Demographics
NPI:1003139981
Name:GRIMALDI, EVANGELINE (RPH)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:
Last Name:GRIMALDI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 SPRING RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2721
Mailing Address - Country:US
Mailing Address - Phone:518-630-6021
Mailing Address - Fax:
Practice Address - Street 1:340 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1978
Practice Address - Country:US
Practice Address - Phone:518-439-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist