Provider Demographics
NPI:1558043794
Name:HUCKELS, GRANT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:HUCKELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 N GRAPE DR APT F303
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1885
Mailing Address - Country:US
Mailing Address - Phone:303-525-9491
Mailing Address - Fax:
Practice Address - Street 1:1005 N STRATFORD RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3512
Practice Address - Country:US
Practice Address - Phone:509-765-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61353596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist