Provider Demographics
NPI:1376857300
Name:GRAVES, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1:200 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:TX
Mailing Address - Zip Code:76648-2446
Mailing Address - Country:US
Mailing Address - Phone:254-576-2241
Mailing Address - Fax:254-576-2496
Practice Address - Street 1:200 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:TX
Practice Address - Zip Code:76648-2446
Practice Address - Country:US
Practice Address - Phone:254-576-2241
Practice Address - Fax:254-576-2496
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist