Provider Demographics
NPI:1659465888
Name:GRAHAM, CHRISTY
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
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:W6769 HWY M69
Mailing Address - Street 2:
Mailing Address - City:FELCH
Mailing Address - State:MI
Mailing Address - Zip Code:49831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-1238
Practice Address - Country:US
Practice Address - Phone:906-563-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302030065OtherPHARMACIST LICENSE NUMBER