Provider Demographics
NPI:1548555410
Name:GROSSE, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:GROSSE
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 1:4777 S 27TH ST
Mailing Address - Street 2:T-0024
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2601
Mailing Address - Country:US
Mailing Address - Phone:414-282-0634
Mailing Address - Fax:414-282-0634
Practice Address - Street 1:4777 S 27TH ST
Practice Address - Street 2:T-0024
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2601
Practice Address - Country:US
Practice Address - Phone:414-282-0634
Practice Address - Fax:414-282-0634
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-18
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9319-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist