Provider Demographics
NPI:1275019705
Name:GREY DOG IV, INC
Entity Type:Organization
Organization Name:GREY DOG IV, INC
Other - Org Name:ETHOS WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT, CPHT
Authorized Official - Phone:305-781-7768
Mailing Address - Street 1:260 CRANDON BLVD STE 33
Mailing Address - Street 2:
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-1538
Mailing Address - Country:US
Mailing Address - Phone:305-982-8727
Mailing Address - Fax:
Practice Address - Street 1:260 CRANDON BLVD STE 33
Practice Address - Street 2:
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149-1538
Practice Address - Country:US
Practice Address - Phone:305-982-8727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH314423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy