Provider Demographics
NPI:1083744916
Name:G AND J GROSS, INC.
Entity Type:Organization
Organization Name:G AND J GROSS, INC.
Other - Org Name:MICKEY FINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-271-6123
Mailing Address - Street 1:433 N ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5001
Mailing Address - Country:US
Mailing Address - Phone:310-271-6123
Mailing Address - Fax:310-273-5339
Practice Address - Street 1:433 N ROXBURY DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5001
Practice Address - Country:US
Practice Address - Phone:310-271-6123
Practice Address - Fax:310-273-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 333600000X, 3336C0004X
CAPHY510553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083744916Medicaid
2136312OtherPK