Provider Demographics
NPI:1891911442
Name:ROSE, SANDRA (RPH)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25049 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:ONAWA
Mailing Address - State:IA
Mailing Address - Zip Code:51040-8696
Mailing Address - Country:US
Mailing Address - Phone:712-423-2068
Mailing Address - Fax:
Practice Address - Street 1:723 WHITTIER ST
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IA
Practice Address - Zip Code:51063-1035
Practice Address - Country:US
Practice Address - Phone:712-458-2500
Practice Address - Fax:712-458-2963
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16649183500000X
NE10783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist