Provider Demographics
NPI:1689715286
Name:GRANDPAS COMPOUNDING PHARMACY INC
Entity Type:Organization
Organization Name:GRANDPAS COMPOUNDING PHARMACY INC
Other - Org Name:GRANDPAS COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-622-2323
Mailing Address - Street 1:7563 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-3917
Mailing Address - Country:US
Mailing Address - Phone:530-622-2323
Mailing Address - Fax:530-622-2011
Practice Address - Street 1:7563 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-3917
Practice Address - Country:US
Practice Address - Phone:530-622-2323
Practice Address - Fax:530-622-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY045878333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155454OtherPK