Provider Demographics
NPI:1922365550
Name:GROUBERT, GARY LEE JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:GROUBERT
Suffix:JR
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 1:40724 CHURCHILL RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-8389
Mailing Address - Country:US
Mailing Address - Phone:330-424-1807
Mailing Address - Fax:
Practice Address - Street 1:40724 CHURCHILL RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-8389
Practice Address - Country:US
Practice Address - Phone:330-424-1807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH031221601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist