Provider Demographics
NPI:1356699565
Name:ROSEN, RUSSELL (RPH)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:ROSEN
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 1:11 DARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-4224
Mailing Address - Country:US
Mailing Address - Phone:917-577-2643
Mailing Address - Fax:
Practice Address - Street 1:1771 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1251
Practice Address - Country:US
Practice Address - Phone:732-534-8559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ17278183500000X
NY35572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist