Provider Demographics
NPI:1881299758
Name:GRADY, WALTER
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:GRADY
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 1:1200 WEST AVE APT 1226
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-4323
Mailing Address - Country:US
Mailing Address - Phone:305-342-0040
Mailing Address - Fax:
Practice Address - Street 1:4800 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3215
Practice Address - Country:US
Practice Address - Phone:305-576-4347
Practice Address - Fax:305-576-1887
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist