Provider Demographics
NPI:1508218538
Name:GRIMES, KASSANDRA (RPH)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1372
Mailing Address - Country:US
Mailing Address - Phone:218-631-4050
Mailing Address - Fax:
Practice Address - Street 1:321 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1372
Practice Address - Country:US
Practice Address - Phone:218-631-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist