Provider Demographics
NPI:1083971329
Name:ROSE, CLALIEN MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:CLALIEN
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1300
Mailing Address - Country:US
Mailing Address - Phone:320-251-3069
Mailing Address - Fax:320-202-9308
Practice Address - Street 1:40 2ND ST S
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1300
Practice Address - Country:US
Practice Address - Phone:320-251-3069
Practice Address - Fax:320-202-9308
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114745183500000X
ND4285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist