Provider Demographics
NPI:1750363636
Name:ELLIS, ROSE (RPH)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:ROSALIE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1200 S SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5532
Mailing Address - Country:US
Mailing Address - Phone:209-595-7147
Mailing Address - Fax:209-461-6890
Practice Address - Street 1:1800 N CALIFORNIA ST
Practice Address - Street 2:HOME INFUSION PHARMACY
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6019
Practice Address - Country:US
Practice Address - Phone:209-461-5486
Practice Address - Fax:209-461-6890
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30597183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30597OtherCALIF. LICENSE NUMBER