Provider Demographics
NPI:1871668020
Name:GRIMMITT, JERRY VANCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:VANCE
Last Name:GRIMMITT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 GOURGE RD
Mailing Address - Street 2:
Mailing Address - City:HENAGAR
Mailing Address - State:AL
Mailing Address - Zip Code:35978
Mailing Address - Country:US
Mailing Address - Phone:256-657-3462
Mailing Address - Fax:
Practice Address - Street 1:785 CHICKAMAUGA AV
Practice Address - Street 2:LONGLEY PHARMACY
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741
Practice Address - Country:US
Practice Address - Phone:706-866-1220
Practice Address - Fax:706-861-7505
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN507183500000X
GA20271183500000X
AL9494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist