Provider Demographics
NPI:1083780183
Name:ROSE PHARMACY INC
Entity Type:Organization
Organization Name:ROSE PHARMACY INC
Other - Org Name:ROSE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHCST
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-235-3383
Mailing Address - Street 1:1074A LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-2923
Mailing Address - Country:US
Mailing Address - Phone:718-235-3383
Mailing Address - Fax:718-235-3381
Practice Address - Street 1:1074A LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-2923
Practice Address - Country:US
Practice Address - Phone:718-235-3383
Practice Address - Fax:718-235-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0246403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02060057Medicaid
2060719OtherPK
NY02060057Medicaid