Provider Demographics
NPI:1073804415
Name:GRANESE, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRANESE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W STOCKTON ST
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:KY
Mailing Address - Zip Code:42129-9458
Mailing Address - Country:US
Mailing Address - Phone:270-432-2725
Mailing Address - Fax:
Practice Address - Street 1:612 W STOCKTON ST
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129-9458
Practice Address - Country:US
Practice Address - Phone:270-432-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist