Provider Demographics
NPI:1922097518
Name:DEMOSS, RODNEY A (RPH)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:A
Last Name:DEMOSS
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 1:507 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4043
Mailing Address - Country:US
Mailing Address - Phone:806-655-1024
Mailing Address - Fax:806-655-9762
Practice Address - Street 1:507 23RD ST
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4043
Practice Address - Country:US
Practice Address - Phone:806-655-1024
Practice Address - Fax:806-655-9762
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142463Medicaid
TX4564731OtherNCPDP
TX6032840001Medicare NSC