Provider Demographics
NPI:1548406408
Name:DA GRAVA, FREDRICK VINCENT (PD, RPH, FASCP)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:VINCENT
Last Name:DA GRAVA
Suffix:
Gender:M
Credentials:PD, RPH, FASCP
Other - Prefix:
Other - First Name:VINCE
Other - Middle Name:
Other - Last Name:DA GRAVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3225 DARLINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2378
Mailing Address - Country:US
Mailing Address - Phone:859-552-5013
Mailing Address - Fax:859-543-0234
Practice Address - Street 1:3225 DARLINGTON CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2378
Practice Address - Country:US
Practice Address - Phone:859-552-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0321661835N0905X
OHRPH 03216613183500000X
WVRP 0005030183500000X
KY011753183500000X
TN0000008755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear