Provider Demographics
NPI:1033714365
Name:GRANDEZ, EMILIO (RPH)
Entity Type:Individual
Prefix:DR
First Name:EMILIO
Middle Name:
Last Name:GRANDEZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 MISTY VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7732
Mailing Address - Country:US
Mailing Address - Phone:617-459-6449
Mailing Address - Fax:
Practice Address - Street 1:3785 SIXES RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-7809
Practice Address - Country:US
Practice Address - Phone:770-720-3466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0290023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060005303OtherDRIVER'S LICENSE