Provider Demographics
NPI:1134157894
Name:GRAHAM SEGO CORPORATION
Entity type:Organization
Organization Name:GRAHAM SEGO CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:321-269-7346
Mailing Address - Street 1:1317 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3312
Mailing Address - Country:US
Mailing Address - Phone:321-269-7346
Mailing Address - Fax:
Practice Address - Street 1:1317 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3312
Practice Address - Country:US
Practice Address - Phone:321-269-7346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0203020001Medicare ID - Type Unspecified