Provider Demographics
NPI:1427167428
Name:GROSS, HEIDI LYNETTE
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNETTE
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3596 N DUBLIN RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1454 W CENTER RD STE 1
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2112
Practice Address - Country:US
Practice Address - Phone:989-895-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist