Provider Demographics
NPI:1962973396
Name:GRICZIN, KIMBERLEY JO
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:JO
Last Name:GRICZIN
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 1:43 FITZHUGH AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-4407
Mailing Address - Country:US
Mailing Address - Phone:410-493-5494
Mailing Address - Fax:
Practice Address - Street 1:720 HANOVER PIKE
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074
Practice Address - Country:US
Practice Address - Phone:410-374-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist