Provider Demographics
NPI:1306327754
Name:GRANBERRY, MOLLEY KAY (PHARMD)
Entity type:Individual
Prefix:
First Name:MOLLEY
Middle Name:KAY
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MOLLEY
Other - Middle Name:KAY
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:544 N ALMA SCHOOL RD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5474
Mailing Address - Country:US
Mailing Address - Phone:520-234-3537
Mailing Address - Fax:
Practice Address - Street 1:9950 E GUADALUPE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2135
Practice Address - Country:US
Practice Address - Phone:480-354-3758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS023337OtherARIZONA STATE BOARD OF PHARMACY