Provider Demographics
NPI:1699956185
Name:GROSSMAN, ROBERT
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 BEATRICE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2010
Mailing Address - Country:US
Mailing Address - Phone:516-783-0351
Mailing Address - Fax:
Practice Address - Street 1:836 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5908
Practice Address - Country:US
Practice Address - Phone:631-665-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01955531Medicaid