Provider Demographics
NPI:1720673643
Name:GRIMWOOD, PAULA MARIE
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIE
Last Name:GRIMWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-2904
Mailing Address - Country:US
Mailing Address - Phone:812-457-5059
Mailing Address - Fax:
Practice Address - Street 1:401 N BURKHARDT RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2733
Practice Address - Country:US
Practice Address - Phone:812-474-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014037A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist