Provider Demographics
NPI:1164568721
Name:W DALE GROSS
Entity Type:Organization
Organization Name:W DALE GROSS
Other - Org Name:GROSS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHCIST
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-686-5191
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98813-1029
Mailing Address - Country:US
Mailing Address - Phone:509-686-5191
Mailing Address - Fax:509-686-5191
Practice Address - Street 1:2520 FOSTER AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WA
Practice Address - Zip Code:98813-1029
Practice Address - Country:US
Practice Address - Phone:509-686-5191
Practice Address - Fax:509-686-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000003293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6145700Medicaid
2106566OtherPK