Provider Demographics
NPI:1659377588
Name:GRAHAM, AGATHA CHRISTIE
Entity Type:Individual
Prefix:DR
First Name:AGATHA
Middle Name:CHRISTIE
Last Name:GRAHAM
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 1:3900 E 12TH ST
Mailing Address - Street 2:APT 223
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3181
Mailing Address - Country:US
Mailing Address - Phone:307-577-7853
Mailing Address - Fax:307-577-2039
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-577-7853
Practice Address - Fax:307-577-2039
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY29981835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy