Provider Demographics
NPI:1104521814
Name:ANIM, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ANIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 NEWBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5384
Mailing Address - Country:US
Mailing Address - Phone:678-598-1544
Mailing Address - Fax:
Practice Address - Street 1:800 BLAKELY ST
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-5329
Practice Address - Country:US
Practice Address - Phone:229-732-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH034036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist