Provider Demographics
NPI:1639762925
Name:VADEN, GRANT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:VADEN
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 1:9424 MAHLER PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3409
Mailing Address - Country:US
Mailing Address - Phone:580-351-7535
Mailing Address - Fax:
Practice Address - Street 1:2100 W BRITTON RD
Practice Address - Street 2:
Practice Address - City:THE VILLAGE
Practice Address - State:OK
Practice Address - Zip Code:73120-1506
Practice Address - Country:US
Practice Address - Phone:405-842-0745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist