Provider Demographics
NPI:1063780278
Name:GRIM, JODI (RPH)
Entity type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:GRIM
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:PO BOX 7281
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0281
Mailing Address - Country:US
Mailing Address - Phone:775-771-1199
Mailing Address - Fax:
Practice Address - Street 1:920 47TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2042
Practice Address - Country:US
Practice Address - Phone:970-353-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15387183500000X
ORRPH-0012887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist