Provider Demographics
NPI:1902407885
Name:GRINDELL, MARILEY M
Entity Type:Individual
Prefix:
First Name:MARILEY
Middle Name:M
Last Name:GRINDELL
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 1:1217 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-5323
Mailing Address - Country:US
Mailing Address - Phone:817-449-3935
Mailing Address - Fax:
Practice Address - Street 1:2245 JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-2319
Practice Address - Country:US
Practice Address - Phone:817-569-6241
Practice Address - Fax:817-569-6242
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist