Provider Demographics
NPI:1063598308
Name:GROSSMAN, RICHARD (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43155 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4117
Mailing Address - Country:US
Mailing Address - Phone:248-348-1570
Mailing Address - Fax:248-348-4316
Practice Address - Street 1:3390 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2323
Practice Address - Country:US
Practice Address - Phone:734-676-6622
Practice Address - Fax:734-676-5725
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302023979OtherPHARMACIST LICENSE NUMBER