Provider Demographics
NPI:1912508847
Name:GRANT, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:GRANT
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 1:12520 MIRAMICHI TRL
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-9768
Mailing Address - Country:US
Mailing Address - Phone:574-952-9200
Mailing Address - Fax:
Practice Address - Street 1:1088 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1816
Practice Address - Country:US
Practice Address - Phone:574-583-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014894A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist