Provider Demographics
NPI:1285812917
Name:GRIGOS, MANOLIS (RPH)
Entity type:Individual
Prefix:MR
First Name:MANOLIS
Middle Name:
Last Name:GRIGOS
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 1:501 FOREST AVENUE
Mailing Address - Street 2:CVS PHARMACY #6051
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3519
Mailing Address - Country:US
Mailing Address - Phone:718-447-1602
Mailing Address - Fax:718-447-8257
Practice Address - Street 1:501 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-3519
Practice Address - Country:US
Practice Address - Phone:718-447-1602
Practice Address - Fax:718-447-8257
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00997517Medicaid