Provider Demographics
NPI:1184666752
Name:GRISWOLD PHARMACY INC
Entity Type:Organization
Organization Name:GRISWOLD PHARMACY INC
Other - Org Name:GRISWOLD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ANKOUNI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-237-9000
Mailing Address - Street 1:1411 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1745
Mailing Address - Country:US
Mailing Address - Phone:313-237-9000
Mailing Address - Fax:313-237-9961
Practice Address - Street 1:1411 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1745
Practice Address - Country:US
Practice Address - Phone:313-237-9000
Practice Address - Fax:313-237-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010077473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046538OtherPK
2046538OtherPK