Provider Demographics
NPI:1003359274
Name:ROSENBACH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSENBACH
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 1:360 BARNSTABLE ROAD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-2089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 BARNSTABLE ROAD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2089
Practice Address - Country:US
Practice Address - Phone:508-771-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23349183500000X
NHR1788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist