Provider Demographics
NPI:1013968023
Name:GRANVILLE MEDICAL PHARMACY INC.
Entity type:Organization
Organization Name:GRANVILLE MEDICAL PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-729-9034
Mailing Address - Street 1:6212 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1903
Mailing Address - Country:US
Mailing Address - Phone:773-274-5888
Mailing Address - Fax:773-274-5961
Practice Address - Street 1:6212 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1903
Practice Address - Country:US
Practice Address - Phone:773-274-5888
Practice Address - Fax:773-274-5961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1438387OtherNAPB
IL1438387OtherNAPB