Provider Demographics
NPI:1780288654
Name:GRIGGS, IVAN EVERETTE (PHARMD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:EVERETTE
Last Name:GRIGGS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 EDITH ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5617
Mailing Address - Country:US
Mailing Address - Phone:850-305-1293
Mailing Address - Fax:
Practice Address - Street 1:13711 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1649
Practice Address - Country:US
Practice Address - Phone:850-305-1293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57639333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy