Provider Demographics
NPI:1417321415
Name:GRANT, EDDIE (CPHT)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 CHASELAKE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-7740
Mailing Address - Country:US
Mailing Address - Phone:678-558-8041
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT 37820183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician