Provider Demographics
NPI:1568006773
Name:GRAVES, OGDEN GEORGE
Entity Type:Individual
Prefix:MR
First Name:OGDEN
Middle Name:GEORGE
Last Name:GRAVES
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 1:3920 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5835
Mailing Address - Country:US
Mailing Address - Phone:239-458-2460
Mailing Address - Fax:
Practice Address - Street 1:3920 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-5835
Practice Address - Country:US
Practice Address - Phone:239-540-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist