Provider Demographics
NPI:1821127069
Name:GROSS, MARIAN E
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:E
Last Name:GROSS
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:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-0591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2902
Practice Address - Country:US
Practice Address - Phone:573-218-6792
Practice Address - Fax:573-218-6762
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000144839183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician