Provider Demographics
NPI:1154887065
Name:GRIMES, PAUL R (PHARMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:GRIMES
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 1:1917 WATERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8521
Mailing Address - Country:US
Mailing Address - Phone:580-656-5654
Mailing Address - Fax:
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-1415
Practice Address - Country:US
Practice Address - Phone:580-925-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist