Provider Demographics
NPI:1881752574
Name:GROSS, NICHOLAS R
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:R
Last Name:GROSS
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 1:504 WOTAN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-3348
Mailing Address - Country:US
Mailing Address - Phone:803-424-0024
Mailing Address - Fax:803-424-0065
Practice Address - Street 1:1023A W DEKALB ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-4162
Practice Address - Country:US
Practice Address - Phone:803-424-0064
Practice Address - Fax:803-424-0065
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist