Provider Demographics
NPI:1639232606
Name:ROSENBERG, MAYNARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:MAYNARD
Middle Name:
Last Name:ROSENBERG
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 1:12815 EAGLE RUN DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-4230
Mailing Address - Country:US
Mailing Address - Phone:402-294-3229
Mailing Address - Fax:402-294-0711
Practice Address - Street 1:106 PEACEKEEPER DR
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-3299
Practice Address - Country:US
Practice Address - Phone:402-294-3229
Practice Address - Fax:402-294-0711
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist