Provider Demographics
NPI:1144778077
Name:ROSE, REGINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 BRENTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHOWCHILLA
Mailing Address - State:CA
Mailing Address - Zip Code:93610-8451
Mailing Address - Country:US
Mailing Address - Phone:559-665-5531
Mailing Address - Fax:559-665-8110
Practice Address - Street 1:23370 ROAD 22
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-8504
Practice Address - Country:US
Practice Address - Phone:559-665-5531
Practice Address - Fax:559-665-8110
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 54637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist