Provider Demographics
NPI:1023159555
Name:GRANBERRY, MARK C (PHARMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:GRANBERRY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 BROADWAY ST
Mailing Address - Street 2:CPO99
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-6318
Mailing Address - Country:US
Mailing Address - Phone:210-805-3025
Mailing Address - Fax:
Practice Address - Street 1:4301 BROADWAY ST
Practice Address - Street 2:CPO99
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6318
Practice Address - Country:US
Practice Address - Phone:210-805-3025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX414971835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy