MEDICARE: DOMINIC DEROSE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	140039-1701	UT

General Provider Information

NPI Number	:	1083698559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC DEROSE JR.

Provider Business Mailing Address
First Line	:	1509 WEST STAYNER DRIVE
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025
Country	:	US
Telephone Number	:	801-451-5708
Fax Number	:

Provider Business Practice Location Address
First Line	:	1080 W 300 N
Second Line	:
City	:	CLEARFIELD
State	:	UT
Zip	:	84015-8732
Country	:	US
Telephone Number	:	801-773-7330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/08/2007

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