Provider Demographics
NPI:1871547919
Name:GRAYLING PHARMACY INC
Entity type:Organization
Organization Name:GRAYLING PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMICIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:EMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-348-6688
Mailing Address - Street 1:208 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-348-6688
Mailing Address - Fax:989-348-1895
Practice Address - Street 1:208 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738
Practice Address - Country:US
Practice Address - Phone:989-348-6688
Practice Address - Fax:989-348-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2357261OtherNCPDP
MI3376241Medicaid
2357261OtherNCPDP