Provider Demographics
NPI:1922154756
Name:GRANGER PHARMACY
Entity type:Organization
Organization Name:GRANGER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:801-597-5650
Mailing Address - Street 1:2965 W 3500 S # W3500S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3639
Mailing Address - Fax:801-965-9641
Practice Address - Street 1:2965 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3602
Practice Address - Country:US
Practice Address - Phone:801-965-3639
Practice Address - Fax:801-965-9641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10310634-17033336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139745OtherPK
UT1922154756Medicaid