Provider Demographics
NPI:1306664727
Name:ROSE, MAKENNA CHEYENNE
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:CHEYENNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8405 NW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2116
Mailing Address - Country:US
Mailing Address - Phone:580-651-3113
Mailing Address - Fax:
Practice Address - Street 1:2345 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5804
Practice Address - Country:US
Practice Address - Phone:405-521-0924
Practice Address - Fax:405-521-0944
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR-20673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist