Provider Demographics
NPI:1467064204
Name:WADE, GRACE (PHARMD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2302
Mailing Address - Country:US
Mailing Address - Phone:620-225-6095
Mailing Address - Fax:620-225-6578
Practice Address - Street 1:1801 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2302
Practice Address - Country:US
Practice Address - Phone:620-225-6095
Practice Address - Fax:620-225-6578
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-103349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist