Provider Demographics
NPI:1871901991
Name:GROSS, GLENN ARTHUR (RPH)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ARTHUR
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 1:4300 MISSOURI FLAT RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6811
Mailing Address - Country:US
Mailing Address - Phone:530-621-3447
Mailing Address - Fax:530-621-3480
Practice Address - Street 1:4300 MISSOURI FLAT RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6811
Practice Address - Country:US
Practice Address - Phone:530-621-3447
Practice Address - Fax:530-621-3480
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40935183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist