Provider Demographics
NPI:1124124896
Name:SUSAN L GRANCEY
Entity type:Organization
Organization Name:SUSAN L GRANCEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-765-5372
Mailing Address - Street 1:304 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-2527
Mailing Address - Country:US
Mailing Address - Phone:814-765-5371
Mailing Address - Fax:814-762-8755
Practice Address - Street 1:304 N 3RD ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-2527
Practice Address - Country:US
Practice Address - Phone:814-765-5371
Practice Address - Fax:814-762-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP413612L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2082296OtherPK
PA0015033180001Medicaid
5044670001Medicare NSC