Provider Demographics
NPI:1669454971
Name:GRIDLEY, DAVID LAURENCE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAURENCE
Last Name:GRIDLEY
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 1:1712 CHASE ARBOR CMN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7412
Mailing Address - Country:US
Mailing Address - Phone:757-962-7346
Mailing Address - Fax:
Practice Address - Street 1:1712 CHASE ARBOR CMN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7412
Practice Address - Country:US
Practice Address - Phone:757-962-7346
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist