Provider Demographics
NPI:1962708594
Name:GRANT, DACIA (RPH)
Entity type:Individual
Prefix:MS
First Name:DACIA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 BRUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2500
Mailing Address - Country:US
Mailing Address - Phone:718-430-9513
Mailing Address - Fax:718-430-1589
Practice Address - Street 1:1998 BRUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2500
Practice Address - Country:US
Practice Address - Phone:718-430-9513
Practice Address - Fax:718-430-1589
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-30
Last Update Date:2011-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055397-1183500000X
CTPCT.0011175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist