Provider Demographics
NPI:1235539479
Name:GROSS, TOMMY JOE (RPH)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:JOE
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 1:1815 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4103
Mailing Address - Country:US
Mailing Address - Phone:208-746-0579
Mailing Address - Fax:208-746-0685
Practice Address - Street 1:1815 21ST ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4103
Practice Address - Country:US
Practice Address - Phone:208-746-0579
Practice Address - Fax:208-746-0685
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist