Provider Demographics
NPI:1396140786
Name:ROSEBERRY, JORDAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3699 HWAY 95
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-9118
Mailing Address - Country:US
Mailing Address - Phone:928-704-5065
Mailing Address - Fax:
Practice Address - Street 1:3699 HWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-9118
Practice Address - Country:US
Practice Address - Phone:928-704-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020979183500000X
NV18878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist