Provider Demographics
NPI:1215537006
Name:ROSARIO, STAR GRACE
Entity Type:Individual
Prefix:
First Name:STAR
Middle Name:GRACE
Last Name:ROSARIO
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 1:10616 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2926
Mailing Address - Country:US
Mailing Address - Phone:702-614-8674
Mailing Address - Fax:
Practice Address - Street 1:10616 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2926
Practice Address - Country:US
Practice Address - Phone:702-614-8674
Practice Address - Fax:702-614-8674
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist