Provider Demographics
NPI:1093522906
Name:GRAHAM, SAGE CHRISTIAN (PHARMD)
Entity type:Individual
Prefix:
First Name:SAGE
Middle Name:CHRISTIAN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6286 ATTALA ROAD 5205
Mailing Address - Street 2:
Mailing Address - City:ETHEL
Mailing Address - State:MS
Mailing Address - Zip Code:39067-5010
Mailing Address - Country:US
Mailing Address - Phone:662-792-7878
Mailing Address - Fax:
Practice Address - Street 1:401 HIGHWAY 12 E
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3823
Practice Address - Country:US
Practice Address - Phone:662-615-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-101804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist