Provider Demographics
NPI:1811371792
Name:GRUSSENDORF, JOEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:GRUSSENDORF
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1878 E HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3104
Mailing Address - Country:US
Mailing Address - Phone:801-647-1857
Mailing Address - Fax:
Practice Address - Street 1:1878 E HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-3104
Practice Address - Country:US
Practice Address - Phone:801-647-1857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7723793-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist