MEDICARE: ROSE ELLIS R.PH.

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	30597	CA
2	1835N1003X	Nutrition Support Pharmacist	30597	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30597	OTHER	CA	CALIF. LICENSE NUMBER

General Provider Information

NPI Number	:	1750363636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE ELLIS R.PH.

Provider Business Mailing Address
First Line	:	1200 S SUNSET DR
Second Line	:
City	:	LODI
State	:	CA
Zip	:	95240-5532
Country	:	US
Telephone Number	:	209-595-7147
Fax Number	:	209-461-6890

Provider Business Practice Location Address
First Line	:	1800 N CALIFORNIA ST
Second Line	:	HOME INFUSION PHARMACY
City	:	STOCKTON
State	:	CA
Zip	:	95204-6019
Country	:	US
Telephone Number	:	209-461-5486
Fax Number	:	209-461-6890

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	09/11/2025

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Directions to “ ROSE ELLIS R.PH.” Practice Location

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