Provider Demographics
NPI:1275913741
Name:GRAVES, JEFFREY RYAN
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BROADALBIN
Mailing Address - State:NY
Mailing Address - Zip Code:12025-2200
Mailing Address - Country:US
Mailing Address - Phone:801-803-1819
Mailing Address - Fax:
Practice Address - Street 1:461 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-1812
Practice Address - Country:US
Practice Address - Phone:518-355-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-31
Last Update Date:2015-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059010-1183500000X
VT033.0101708183500000X
UT7000548-01701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist