Provider Demographics
NPI:1376006502
Name:GROSSMAN, TODD
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 E US HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8758
Mailing Address - Country:US
Mailing Address - Phone:719-687-4308
Mailing Address - Fax:719-687-6895
Practice Address - Street 1:19600 E US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8758
Practice Address - Country:US
Practice Address - Phone:719-687-4308
Practice Address - Fax:719-687-6895
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist