Healthcare Provider Details

I. General information

NPI: 1669081956
Provider Name (Legal Business Name): JOHN R ROSA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 NW VICTORIA DR STE B
LEES SUMMIT MO
64086-4709
US

IV. Provider business mailing address

255 NW VICTORIA DR STE B
LEES SUMMIT MO
64086-4709
US

V. Phone/Fax

Practice location:
  • Phone: 855-937-7273
  • Fax: 844-878-6793
Mailing address:
  • Phone: 855-937-7273
  • Fax: 844-878-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2021051192
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number023980
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302415724
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-109420
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202221730
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: