Provider Demographics
NPI:1720263452
Name:ROSS, CHAD THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:THOMAS
Last Name:ROSS
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 1:3 SUGAR PINE RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3761 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1837
Practice Address - Country:US
Practice Address - Phone:518-623-2993
Practice Address - Fax:518-623-3169
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist