Provider Demographics
NPI:1457453706
Name:ROOS, RICHARD G (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:G
Last Name:ROOS
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 1:2150 W. NORTHSHORE DR
Mailing Address - Street 2:PO BOX 817
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661
Mailing Address - Country:US
Mailing Address - Phone:313-925-0169
Mailing Address - Fax:
Practice Address - Street 1:131 KERCHEVAL AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3629
Practice Address - Country:US
Practice Address - Phone:313-640-2591
Practice Address - Fax:313-640-2589
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302026812OtherPHARMACIST LICENSE