Provider Demographics
NPI:1912209032
Name:GRANT, CAMILLE ROSE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:ROSE
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 PRESTON LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2626
Mailing Address - Country:US
Mailing Address - Phone:209-380-0929
Mailing Address - Fax:
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:209-735-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 61143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist