Provider Demographics
NPI:1275949356
Name:GRAPENTINE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GRAPENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 ADAMS ST
Mailing Address - Street 2:T-0663
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4864
Mailing Address - Country:US
Mailing Address - Phone:507-625-9009
Mailing Address - Fax:
Practice Address - Street 1:1850 ADAMS ST
Practice Address - Street 2:T-0663
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4864
Practice Address - Country:US
Practice Address - Phone:952-201-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist