Provider Demographics
NPI:1063496370
Name:GROSS, JOHN DANIEL (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
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 1:6133 ROLFE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-1025
Mailing Address - Country:US
Mailing Address - Phone:757-451-8052
Mailing Address - Fax:
Practice Address - Street 1:247 EXPRESSWAY CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6526
Practice Address - Country:US
Practice Address - Phone:757-499-9637
Practice Address - Fax:757-473-9227
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist