Provider Demographics
NPI:1942841762
Name:GRANT, GARY WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WILLIAM
Last Name:GRANT
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 1:730 CASEY TER
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-4630
Mailing Address - Country:US
Mailing Address - Phone:757-871-3785
Mailing Address - Fax:
Practice Address - Street 1:13349 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-5601
Practice Address - Country:US
Practice Address - Phone:757-877-0253
Practice Address - Fax:757-872-9247
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist