Provider Demographics
NPI:1922634104
Name:GROSSKREUZ, SUSAN MARGARET (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET
Last Name:GROSSKREUZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6868 NORTHVUE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-8101
Mailing Address - Country:US
Mailing Address - Phone:262-353-2771
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST STE 100
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2684
Practice Address - Country:US
Practice Address - Phone:262-670-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12078-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist