=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306339569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN ROGOSZEWSKI PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2018
-----------------------------------------------------
Last Update Date | 06/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3531 WINDMILL DR APT T6
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80526-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-290-3563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3531 WINDMILL DR APT T6
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80526-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-290-3563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302039910
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PHA.0021060
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------