Provider Demographics
NPI:1619570975
Name:MCCULLOUGH, GRANT (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1672
Mailing Address - Country:US
Mailing Address - Phone:262-473-2225
Mailing Address - Fax:262-473-2226
Practice Address - Street 1:1173 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1672
Practice Address - Country:US
Practice Address - Phone:262-473-2225
Practice Address - Fax:262-473-2226
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17069-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist