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General NPI Number Information
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NPI Number | 1225401219
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Entity Type | Individual
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Provider Name | TRAVIS RYAN GROSS
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Gender | Male
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Dates
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Enumeration Date | 11/12/2015
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 901 LOWER PLN
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City | BRADFORD
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State | VT
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Zip | 05033
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Country | US
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Telephone | 802-222-9292
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Fax |
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Provider Business Mailing Address
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Address Line | 901 LOWER PLN
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City | BRADFORD
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State | VT
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Zip | 05033-8924
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Country | US
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Telephone | 802-222-9292
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 061088
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 033.0134102
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License Number State | VT
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