Provider Demographics
NPI:1184260713
Name:GRAHAM, TATIANA VASILIEVNA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:VASILIEVNA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:TATIANA
Other - Middle Name:VASILIEVNA
Other - Last Name:MCCLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:71210 INDIANA LAKE DR
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MI
Mailing Address - Zip Code:49130
Mailing Address - Country:US
Mailing Address - Phone:574-265-9640
Mailing Address - Fax:
Practice Address - Street 1:901 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3329
Practice Address - Country:US
Practice Address - Phone:574-264-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023521A183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist