Provider Demographics
NPI:1629678545
Name:GROSS, MONICA NICHOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:NICHOLE
Last Name:GROSS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 HERRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4237
Mailing Address - Country:US
Mailing Address - Phone:706-399-0026
Mailing Address - Fax:
Practice Address - Street 1:2205 HARRISON RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7455
Practice Address - Country:US
Practice Address - Phone:706-595-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist