Provider Demographics
NPI:1942972203
Name:GROS, RAY
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:GROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9943 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3107
Mailing Address - Country:US
Mailing Address - Phone:619-443-1013
Mailing Address - Fax:619-443-8517
Practice Address - Street 1:9943 MAINE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3107
Practice Address - Country:US
Practice Address - Phone:619-443-1013
Practice Address - Fax:619-443-8517
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH43143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist