Provider Demographics
NPI:1124476502
Name:GRIESBAUM, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GRIESBAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-2421
Mailing Address - Country:US
Mailing Address - Phone:724-728-7259
Mailing Address - Fax:
Practice Address - Street 1:87 WAGNER RD
Practice Address - Street 2:
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-2421
Practice Address - Country:US
Practice Address - Phone:724-728-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028025183500000X
WV0009366183500000X
SC35644183500000X
OH3135423183500000X
PA449982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist