Provider Demographics
NPI:1194087478
Name:MICHAEL, RICHARD GRANDVILLE (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GRANDVILLE
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 WOODCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7183
Mailing Address - Country:US
Mailing Address - Phone:417-725-9302
Mailing Address - Fax:
Practice Address - Street 1:1311 WOODCASTLE RD
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7183
Practice Address - Country:US
Practice Address - Phone:417-725-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0420271835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric