Provider Demographics
NPI:1699361097
Name:GRANAT, GARY STEPHEN
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEPHEN
Last Name:GRANAT
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 1:2387 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVAN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1651
Mailing Address - Country:US
Mailing Address - Phone:248-302-4122
Mailing Address - Fax:
Practice Address - Street 1:2387 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:SYLVAN LAKE
Practice Address - State:MI
Practice Address - Zip Code:48320-1651
Practice Address - Country:US
Practice Address - Phone:248-302-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist