Provider Demographics
NPI:1174070452
Name:MICHAEL GRANT
Entity type:Organization
Organization Name:MICHAEL GRANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM
Authorized Official - Phone:860-869-7251
Mailing Address - Street 1:1492 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1287
Mailing Address - Country:US
Mailing Address - Phone:631-843-0500
Mailing Address - Fax:
Practice Address - Street 1:4 DADEN LN
Practice Address - Street 2:
Practice Address - City:WEST SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06092-2703
Practice Address - Country:US
Practice Address - Phone:860-869-7251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00011965302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization