Provider Demographics
NPI:1003404682
Name:GROTH, MITCHELL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:GROTH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 N STORY PKWY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3618
Mailing Address - Country:US
Mailing Address - Phone:262-501-7371
Mailing Address - Fax:
Practice Address - Street 1:N85W15882 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3082
Practice Address - Country:US
Practice Address - Phone:262-437-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist