=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922097518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODNEY A DEMOSS RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2005
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 507 23RD ST
-----------------------------------------------------
City | CANYON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79015-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-655-1024
-----------------------------------------------------
Fax | 806-655-9762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 23RD ST
-----------------------------------------------------
City | CANYON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79015-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-655-1024
-----------------------------------------------------
Fax | 806-655-9762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 10210
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------