Provider Demographics
NPI:1437221223
Name:ROGUE ENTERPRISES INC
Entity Type:Organization
Organization Name:ROGUE ENTERPRISES INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSNELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-456-7890
Mailing Address - Street 1:231 W LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-9282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 W LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-9282
Practice Address - Country:US
Practice Address - Phone:937-456-7890
Practice Address - Fax:937-456-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02112300333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2125471Medicaid
3666700OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OHBM6365022OtherDEA #
OHRORV93191Medicare PIN
OHBM6365022OtherDEA #