Provider Demographics
NPI:1285627034
Name:GRANILLO, MARIO RENE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:RENE
Last Name:GRANILLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 N DIAMOND BUTTE WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-7128
Mailing Address - Country:US
Mailing Address - Phone:520-591-0252
Mailing Address - Fax:520-670-3842
Practice Address - Street 1:839 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2819
Practice Address - Country:US
Practice Address - Phone:520-205-4996
Practice Address - Fax:520-670-3842
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist