Provider Demographics
NPI:1437697174
Name:GRACEMED HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:GRACEMED HEALTH CLINIC, INC
Other - Org Name:GRACEMED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-866-2064
Mailing Address - Street 1:1122 N TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2810
Mailing Address - Country:US
Mailing Address - Phone:316-866-2000
Mailing Address - Fax:
Practice Address - Street 1:1122 N TOPEKA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2810
Practice Address - Country:US
Practice Address - Phone:316-866-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy