Healthcare Provider Details

I. General information

NPI: 1013878008
Provider Name (Legal Business Name): KEITH JACOB ROSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 PARK BLVD
WILDWOOD NJ
08260-1498
US

IV. Provider business mailing address

5100 PARK BLVD
WILDWOOD NJ
08260-1498
US

V. Phone/Fax

Practice location:
  • Phone: 609-523-6704
  • Fax:
Mailing address:
  • Phone: 609-523-6704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP460043
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04470700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: