Provider Demographics
NPI:1164746277
Name:GRISIK, MATTHEW S (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:S
Last Name:GRISIK
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 1:3105 WOODVALE CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1923
Mailing Address - Country:US
Mailing Address - Phone:770-475-2759
Mailing Address - Fax:
Practice Address - Street 1:3105 WOODVALE CT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1923
Practice Address - Country:US
Practice Address - Phone:770-475-2759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025008183500000X
OH03-3-21664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist