Provider Demographics
NPI:1881726396
Name:GROSS, GEORGE WILLIS (RPH)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WILLIS
Last Name:GROSS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 APPLEGATE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7976
Mailing Address - Country:US
Mailing Address - Phone:813-685-5461
Mailing Address - Fax:813-685-5461
Practice Address - Street 1:65 3RD ST NW STE 59
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4674
Practice Address - Country:US
Practice Address - Phone:863-401-9300
Practice Address - Fax:863-401-9330
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist