Healthcare Provider Details

I. General information

NPI: 1992104863
Provider Name (Legal Business Name): JONATHAN DE ROSALES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 08/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W STEPHENSON ST
FREEPORT IL
61032-4864
US

IV. Provider business mailing address

1045 W STEPHENSON ST
FREEPORT IL
61032-4864
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051297755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: