Provider Demographics
NPI:1588626857
Name:ROSCELLI, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:ROSCELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 YACHT HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-1126
Mailing Address - Country:US
Mailing Address - Phone:209-942-4344
Mailing Address - Fax:
Practice Address - Street 1:4725 QUAIL LAKES DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5243
Practice Address - Country:US
Practice Address - Phone:209-952-3599
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist