Provider Demographics
NPI:1558402073
Name:GROVE, ERIK RANDALL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ERIK
Middle Name:RANDALL
Last Name:GROVE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 SAINT ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8942
Mailing Address - Country:US
Mailing Address - Phone:502-222-9678
Mailing Address - Fax:812-273-6666
Practice Address - Street 1:835 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3131
Practice Address - Country:US
Practice Address - Phone:812-265-4621
Practice Address - Fax:812-273-6666
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12150183500000X
IN26022241A183500000X
IL51291460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9023441000OtherKENTUCKY MEDICAID DME
KY54023718Medicaid