Provider Demographics
NPI:1366901191
Name:GRUNEWALD, NICHOLAS MARKS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MARKS
Last Name:GRUNEWALD
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 1:325 MDG/SGAP
Mailing Address - Street 2:340 MAGNOLIA CIR.
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403
Mailing Address - Country:US
Mailing Address - Phone:850-283-7377
Mailing Address - Fax:
Practice Address - Street 1:325 MDG, 340 MAGNOLIA CIRCLE
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:850-283-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist