Provider Demographics
NPI:1205009016
Name:GRISMER, ALISA BROOKE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:BROOKE
Last Name:GRISMER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15800 95TH AVE N
Mailing Address - Street 2:PARK NICOLLET
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4400
Mailing Address - Country:US
Mailing Address - Phone:952-993-1414
Mailing Address - Fax:952-993-1389
Practice Address - Street 1:15800 95TH AVE N
Practice Address - Street 2:PARK NICOLLET
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4400
Practice Address - Country:US
Practice Address - Phone:952-993-1414
Practice Address - Fax:952-993-1389
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-12
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist