Provider Demographics
NPI:1891978268
Name:GRANGE, ANDREA EMILY
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:EMILY
Last Name:GRANGE
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 1:14960 257TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2704
Mailing Address - Country:US
Mailing Address - Phone:718-341-9712
Mailing Address - Fax:
Practice Address - Street 1:14960 257TH ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2704
Practice Address - Country:US
Practice Address - Phone:718-341-9712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist