Provider Demographics
NPI:1215457817
Name:GROSS, JOHN W (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:GROSS
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 1:11271 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-9439
Mailing Address - Country:US
Mailing Address - Phone:989-339-9008
Mailing Address - Fax:855-855-4919
Practice Address - Street 1:1048 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1154
Practice Address - Country:US
Practice Address - Phone:989-386-2900
Practice Address - Fax:989-386-3710
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5302027910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365496Medicaid