Provider Demographics
NPI:1861714719
Name:ROSS, REX M (RPH)
Entity type:Individual
Prefix:MR
First Name:REX
Middle Name:M
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 1:7766 N HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-8229
Mailing Address - Country:US
Mailing Address - Phone:989-821-7387
Mailing Address - Fax:
Practice Address - Street 1:8171 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9165
Practice Address - Country:US
Practice Address - Phone:989-422-6445
Practice Address - Fax:989-422-5136
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302023130OtherSTATE PHARMACY LICENSE