Provider Demographics
NPI:1235342882
Name:GROSS, TIFFANY MONIQUE (CPHT)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:MONIQUE
Last Name:GROSS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15910 SPRINGS VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4917
Mailing Address - Country:US
Mailing Address - Phone:313-525-9285
Mailing Address - Fax:
Practice Address - Street 1:7800 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3461
Practice Address - Country:US
Practice Address - Phone:313-653-2200
Practice Address - Fax:313-255-2091
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI330100105110272183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician