Provider Demographics
NPI:1124275383
Name:GROVER, THANE Z (PHARMD)
Entity type:Individual
Prefix:
First Name:THANE
Middle Name:Z
Last Name:GROVER
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:PO BOX 11
Mailing Address - Street 2:883 STUMP CREEK RD
Mailing Address - City:AUBURN
Mailing Address - State:WY
Mailing Address - Zip Code:83111-0011
Mailing Address - Country:US
Mailing Address - Phone:307-413-1335
Mailing Address - Fax:
Practice Address - Street 1:141 N. WASHINGTON ST.
Practice Address - Street 2:BROULIM'S PHARMACY
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:307-885-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6205183500000X
ORRPH-0012033183500000X
WY3605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist