Provider Demographics
NPI:1407991375
Name:GROSS, JACK B (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:GROSS
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 1:106 CHERRY DR
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-9219
Mailing Address - Country:US
Mailing Address - Phone:859-324-5543
Mailing Address - Fax:
Practice Address - Street 1:106 CHERRY DR
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330
Practice Address - Country:US
Practice Address - Phone:859-324-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY008544OtherLICENSE NUMBER