Provider Demographics
NPI:1669105540
Name:GRANDE, JOSE JR (PHT)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GRANDE
Suffix:JR
Gender:M
Credentials:PHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W EDINGER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-4307
Mailing Address - Country:US
Mailing Address - Phone:714-546-6191
Mailing Address - Fax:714-546-5037
Practice Address - Street 1:1406 W EDINGER AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-4307
Practice Address - Country:US
Practice Address - Phone:714-546-6191
Practice Address - Fax:714-546-5037
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104218183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician