Provider Demographics
NPI:1811163736
Name:GRANDSTAFF, THOMAS D
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:GRANDSTAFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2311
Mailing Address - Country:US
Mailing Address - Phone:954-452-2828
Mailing Address - Fax:
Practice Address - Street 1:340 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2547
Practice Address - Country:US
Practice Address - Phone:954-764-1584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26804183500000X
IN26014298A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist