Provider Demographics
NPI:1255705349
Name:GRANE SUPPLY, INC.
Entity type:Organization
Organization Name:GRANE SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FUNDERLICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-449-0690
Mailing Address - Street 1:105 GAMMA DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238
Mailing Address - Country:US
Mailing Address - Phone:412-449-0680
Mailing Address - Fax:129-685-8004
Practice Address - Street 1:340 N MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-891-5783
Practice Address - Fax:610-891-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
PAPP4826183336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482618OtherBOARD OF PHARMACY
PA1008270470004Medicaid