Provider Demographics
NPI:1902506611
Name:GRANDISON, STACEY CARTER II (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:CARTER
Last Name:GRANDISON
Suffix:II
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 1:11414 W MARKHAM ST STE D
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2806
Mailing Address - Country:US
Mailing Address - Phone:501-904-4299
Mailing Address - Fax:
Practice Address - Street 1:11414 W MARKHAM ST STE D
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2806
Practice Address - Country:US
Practice Address - Phone:501-904-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist