Provider Demographics
NPI:1881774768
Name:ROSE, CHERYL M (RPH)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 OLD LIVERPOOL RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6087
Mailing Address - Country:US
Mailing Address - Phone:607-753-7181
Mailing Address - Fax:607-753-7181
Practice Address - Street 1:642 OLD LIVERPOOL RD
Practice Address - Street 2:PHARMACANNIS
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6087
Practice Address - Country:US
Practice Address - Phone:315-457-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02189944Medicaid