Provider Demographics
NPI:1689657454
Name:GRANDMAS COUNTRY PHARMACY INC
Entity Type:Organization
Organization Name:GRANDMAS COUNTRY PHARMACY INC
Other - Org Name:GRANDMAS COUNTRY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLORIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:362-236-0407
Mailing Address - Street 1:11386 E HIGHWAY 316
Mailing Address - Street 2:
Mailing Address - City:FORT MC COY
Mailing Address - State:FL
Mailing Address - Zip Code:32134-8114
Mailing Address - Country:US
Mailing Address - Phone:352-236-0407
Mailing Address - Fax:352-236-6343
Practice Address - Street 1:11386 E HIGHWAY 316
Practice Address - Street 2:
Practice Address - City:FORT MC COY
Practice Address - State:FL
Practice Address - Zip Code:32134-8114
Practice Address - Country:US
Practice Address - Phone:352-236-0407
Practice Address - Fax:352-236-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH00167313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021480900Medicaid
2012542OtherPK