Provider Demographics
NPI:1376271031
Name:GRINBERG, TATYANA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:GRINBERG
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 1:15216 FAIRWAY HEIGHTS RD NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3600
Mailing Address - Country:US
Mailing Address - Phone:195-220-0486
Mailing Address - Fax:
Practice Address - Street 1:8100 W COUNTY ROAD 42
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2193
Practice Address - Country:US
Practice Address - Phone:952-226-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist