Provider Demographics
NPI:1194134742
Name:ROSE, CLIFTON THOMAS (PHARMACIST)
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:THOMAS
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-3710
Mailing Address - Country:US
Mailing Address - Phone:949-701-3996
Mailing Address - Fax:
Practice Address - Street 1:2300 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-3710
Practice Address - Country:US
Practice Address - Phone:714-998-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30186183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist