Provider Demographics
NPI:1366575219
Name:PROSS, JOHN ADAM (PHG)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ADAM
Last Name:PROSS
Suffix:
Gender:M
Credentials:PHG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1529
Mailing Address - Country:US
Mailing Address - Phone:315-635-0919
Mailing Address - Fax:
Practice Address - Street 1:106 ARTERIAL RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NE
Practice Address - Zip Code:13206
Practice Address - Country:US
Practice Address - Phone:315-437-0699
Practice Address - Fax:315-433-9091
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist