Provider Demographics
NPI:1457581316
Name:ROSE, MICHAEL LAWRENCE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118A NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-4225
Mailing Address - Country:US
Mailing Address - Phone:817-690-5081
Mailing Address - Fax:
Practice Address - Street 1:1901 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist