Provider Demographics
NPI:1336980309
Name:GRAHAM, GABRIELLE (PHARMD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CARL ONEAL RD
Mailing Address - Street 2:
Mailing Address - City:PERKINSTON
Mailing Address - State:MS
Mailing Address - Zip Code:39573-5072
Mailing Address - Country:US
Mailing Address - Phone:662-401-2178
Mailing Address - Fax:
Practice Address - Street 1:9350 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4213
Practice Address - Country:US
Practice Address - Phone:228-864-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist