Provider Demographics
NPI:1932344124
Name:SOULOS, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:SOULOS
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 1:1660 WALT WHITMAN RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4159
Mailing Address - Country:US
Mailing Address - Phone:631-845-8495
Mailing Address - Fax:
Practice Address - Street 1:1660 WALT WHITMAN RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4159
Practice Address - Country:US
Practice Address - Phone:631-845-8495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist