Provider Demographics
NPI:1104183342
Name:GRUBBS PHARMACY SE INC
Entity type:Organization
Organization Name:GRUBBS PHARMACY SE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:202-543-4400
Mailing Address - Street 1:1800 MARTIN LUTHER KING JR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-6900
Mailing Address - Country:US
Mailing Address - Phone:202-503-3610
Mailing Address - Fax:202-503-2639
Practice Address - Street 1:1800 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6900
Practice Address - Country:US
Practice Address - Phone:202-503-3610
Practice Address - Fax:202-503-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
DCRX12000113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135251OtherPK