Provider Demographics
NPI:1598092793
Name:GROTH, STEPHEN JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JAMES
Last Name:GROTH
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:S 5970 COUNTY N
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665
Mailing Address - Country:US
Mailing Address - Phone:608-689-2543
Mailing Address - Fax:
Practice Address - Street 1:S 5970 COUNTY N
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665
Practice Address - Country:US
Practice Address - Phone:608-689-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117337183500000X
IA19394183500000X
WI11989-040183500000X
IL051.039240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist