Provider Demographics
NPI:1578069860
Name:GRANT, MARJORIE ANNE
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ANNE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8703
Mailing Address - Country:US
Mailing Address - Phone:575-443-7933
Mailing Address - Fax:
Practice Address - Street 1:2559 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8703
Practice Address - Country:US
Practice Address - Phone:575-443-7933
Practice Address - Fax:575-443-7910
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT00009594183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician