Provider Demographics
NPI:1699497586
Name:GRILLIOT, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GRILLIOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 REED AVE
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:OH
Mailing Address - Zip Code:45380-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9101 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1927
Practice Address - Country:US
Practice Address - Phone:937-423-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03442544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist