Healthcare Provider Details

I. General information

NPI: 1699368662
Provider Name (Legal Business Name): HALEY GROSSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N WASHINGTON AVE
DALLAS TX
75246-1754
US

IV. Provider business mailing address

122 SANDY LN
WACO TX
76708-7009
US

V. Phone/Fax

Practice location:
  • Phone: 254-202-1266
  • Fax:
Mailing address:
  • Phone: 254-202-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: