Basic Information
| Provider Information | |||||||||
| NPI: | 1518931302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH FASCP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSE | ||||||||
| OtherFirstName: | ROGER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1725 N AGUILA DR | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282317936 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2896844380 | ||||||||
| FaxNumber: | 9286845499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 2001029149 | MO | N | Pharmacy Service Providers | Pharmacist | 183500000X | 051037642 | IL | N | Pharmacy Service Providers | Pharmacist | 183500000X | 15754 | IA | N | Pharmacy Service Providers | Pharmacist | 183500000X | S015899 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.