Provider Demographics
NPI:1033496526
Name:GRIESE, ROMAN BLAKE (PHARMD, JD)
Entity Type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:BLAKE
Last Name:GRIESE
Suffix:
Gender:M
Credentials:PHARMD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5549 GUILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3244
Mailing Address - Country:US
Mailing Address - Phone:765-491-1696
Mailing Address - Fax:
Practice Address - Street 1:5549 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3244
Practice Address - Country:US
Practice Address - Phone:765-491-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022556A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist