Provider Demographics
NPI:1497146864
Name:GROSSTEPHAN, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GROSSTEPHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2003
Mailing Address - Country:US
Mailing Address - Phone:315-233-0601
Mailing Address - Fax:315-233-0611
Practice Address - Street 1:3657 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2003
Practice Address - Country:US
Practice Address - Phone:315-233-0601
Practice Address - Fax:315-233-0611
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician