Provider Demographics
NPI:1437472123
Name:GRIMM, MATTHEW (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRIMM
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 1:3175 CHILI AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-5423
Mailing Address - Country:US
Mailing Address - Phone:585-426-2330
Mailing Address - Fax:585-426-5148
Practice Address - Street 1:3175 CHILI AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5423
Practice Address - Country:US
Practice Address - Phone:585-426-2330
Practice Address - Fax:585-426-5148
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052631OtherPHARMACIST LICENSE #