Provider Demographics
NPI:1265653661
Name:ROSE, MICHAEL HENRY (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HENRY
Last Name:ROSE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MELANIE LN
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-9496
Mailing Address - Country:US
Mailing Address - Phone:601-892-2546
Mailing Address - Fax:
Practice Address - Street 1:218 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2712
Practice Address - Country:US
Practice Address - Phone:601-894-1222
Practice Address - Fax:601-894-1522
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0030881Medicaid