Healthcare Provider Details

I. General information

NPI: 1184327819
Provider Name (Legal Business Name): MELISSA ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 E PERRY ST
PORT CLINTON OH
43452-1332
US

IV. Provider business mailing address

1108 COLUMBIA AVE
PORT CLINTON OH
43452-2208
US

V. Phone/Fax

Practice location:
  • Phone: 419-734-5583
  • Fax: 419-734-0853
Mailing address:
  • Phone: 419-341-8128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number300101041154016
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: