Provider Demographics
NPI:1780988535
Name:GRAVDAL, MARK NORMAN (RPH, CGP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:NORMAN
Last Name:GRAVDAL
Suffix:
Gender:M
Credentials:RPH, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3345
Mailing Address - Country:US
Mailing Address - Phone:815-479-8363
Mailing Address - Fax:
Practice Address - Street 1:297 CASCADE DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3345
Practice Address - Country:US
Practice Address - Phone:815-479-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510300011835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric