Provider Demographics
NPI:1326463902
Name:GRZYWACZ, ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GRZYWACZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3728 N. PRINCE ST.
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2389
Mailing Address - Fax:575-769-2495
Practice Address - Street 1:3728 N. PRINCE ST.
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2389
Practice Address - Fax:575-769-2495
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist