Provider Demographics
NPI:1548868599
Name:GRISWOLD, KEVIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:GRISWOLD
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 1:3920 EXCELSIOR BLVD UNIT 213
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5351
Mailing Address - Country:US
Mailing Address - Phone:612-400-3424
Mailing Address - Fax:
Practice Address - Street 1:13020 RIVERDALE DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1057
Practice Address - Country:US
Practice Address - Phone:763-421-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist