Provider Demographics
NPI:1083995377
Name:GROTA, MICHAEL WHITNEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WHITNEY
Last Name:GROTA
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 1:1300 EGG HARBOR RD STE 112
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1248
Mailing Address - Country:US
Mailing Address - Phone:920-746-2977
Mailing Address - Fax:920-746-2962
Practice Address - Street 1:1300 EGG HARBOR RD STE 112
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1248
Practice Address - Country:US
Practice Address - Phone:920-746-2977
Practice Address - Fax:920-746-2962
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16478-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist