Provider Demographics
NPI:1083906077
Name:GRUBB, CHARLES CARLON
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CARLON
Last Name:GRUBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:BRIDGEHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11932-0625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 MONTAUK HWY UNIT A
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1156
Practice Address - Country:US
Practice Address - Phone:631-874-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist