Provider Demographics
NPI:1912680398
Name:GRANT, PUMA LL (RPH)
Entity Type:Individual
Prefix:
First Name:PUMA
Middle Name:LL
Last Name:GRANT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 EASTERN PKWY FL 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3405
Mailing Address - Country:US
Mailing Address - Phone:201-719-3649
Mailing Address - Fax:
Practice Address - Street 1:209 EASTERN PKWY FL 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3405
Practice Address - Country:US
Practice Address - Phone:201-719-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04319700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist