Provider Demographics
NPI:1649689191
Name:SUDHOLT, GRANT (RPH)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:SUDHOLT
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:PO BOX 1673
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-1673
Mailing Address - Country:US
Mailing Address - Phone:505-710-3452
Mailing Address - Fax:
Practice Address - Street 1:66 STATE ROAD 344
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-6849
Practice Address - Country:US
Practice Address - Phone:505-286-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP6453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist