Provider Demographics
NPI:1518931302
Name:ROSE, ROGER L (RPH FASCP)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:L
Last Name:ROSE
Suffix:
Gender:M
Credentials:RPH FASCP
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1725 N AGUILA DR
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1101
Mailing Address - Country:US
Mailing Address - Phone:928-231-7936
Mailing Address - Fax:
Practice Address - Street 1:520 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1447
Practice Address - Country:US
Practice Address - Phone:289-684-4380
Practice Address - Fax:928-684-5499
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001029149183500000X
IL051037642183500000X
IA15754183500000X
AZS015899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0104547Medicaid
IA0104547Medicaid
IA0382680001Medicare NSC