Provider Demographics
NPI:1790408243
Name:GRAHAM, MARJORIE KAREN
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:KAREN
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 1:505 COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4306
Mailing Address - Country:US
Mailing Address - Phone:912-429-3216
Mailing Address - Fax:
Practice Address - Street 1:2055 E VICTORY DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-3716
Practice Address - Country:US
Practice Address - Phone:912-352-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH014977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH014977OtherGEORGIA BOARD OF PHARMACY