Healthcare Provider Details

I. General information

NPI: 1316585581
Provider Name (Legal Business Name): DEBORAH MAGOUN ROSENBAUM PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEBORAH.ROSENBAUM@STORES.KROGER.COM 4910 I-55 NORTH
JACKSON MS
39211
US

IV. Provider business mailing address

DEBORAH.ROSENBAUM@STORES.KROGER.COM 4910 I-55 NORTH
JACKSON MS
39211
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-6554
  • Fax: 601-987-8382
Mailing address:
  • Phone: 601-366-6554
  • Fax: 601-987-8382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE-07632
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: