Provider Demographics
NPI:1184327819
Name:ROSE, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
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 1:1108 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2208
Mailing Address - Country:US
Mailing Address - Phone:419-341-8128
Mailing Address - Fax:
Practice Address - Street 1:1626 E PERRY ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1332
Practice Address - Country:US
Practice Address - Phone:419-734-5583
Practice Address - Fax:419-734-0853
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300101041154016183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician