Provider Demographics
NPI:1790422731
Name:ROSE, SAVANNAH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 OAK GROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:TYNER
Mailing Address - State:KY
Mailing Address - Zip Code:40486-8396
Mailing Address - Country:US
Mailing Address - Phone:606-386-0318
Mailing Address - Fax:
Practice Address - Street 1:1165 OAK GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:TYNER
Practice Address - State:KY
Practice Address - Zip Code:40486-8396
Practice Address - Country:US
Practice Address - Phone:606-386-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYI14684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist