Provider Demographics
NPI:1699368662
Name:GROSSE, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:GROSSE
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 1:122 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-7009
Mailing Address - Country:US
Mailing Address - Phone:254-202-1266
Mailing Address - Fax:
Practice Address - Street 1:301 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1754
Practice Address - Country:US
Practice Address - Phone:254-202-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician