Provider Demographics
NPI:1962402164
Name:DR GRAM PHARMACY, INC.
Entity type:Organization
Organization Name:DR GRAM PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GRAMLICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:760-741-9804
Mailing Address - Street 1:909 E VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3428
Mailing Address - Country:US
Mailing Address - Phone:760-741-9804
Mailing Address - Fax:760-741-0584
Practice Address - Street 1:909 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3428
Practice Address - Country:US
Practice Address - Phone:760-741-9804
Practice Address - Fax:760-741-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50645333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA410170Medicaid
CAPHY410170Medicaid
CA0311450009Medicare NSC