Provider Demographics
NPI:1164717799
Name:GRANDQUEST, MARY M (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:GRANDQUEST
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 1:1698 HIGHWAY 98
Mailing Address - Street 2:TARGET-1274
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4252
Mailing Address - Country:US
Mailing Address - Phone:251-626-5739
Mailing Address - Fax:251-626-5739
Practice Address - Street 1:1698 HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4252
Practice Address - Country:US
Practice Address - Phone:251-626-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist