1114074689 NPI number — MR. RICHARD ROSTHOLDER R.PH

Table of content: MR. RICHARD ROSTHOLDER R.PH (NPI 1114074689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114074689 NPI number — MR. RICHARD ROSTHOLDER R.PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSTHOLDER
Provider First Name:
RICHARD
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114074689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20419 HILLSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLIS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11423-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-465-2121
Provider Business Mailing Address Fax Number:
718-217-9794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20419 HILLSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11423-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-465-2121
Provider Business Practice Location Address Fax Number:
718-217-9794
Provider Enumeration Date:
01/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  32723 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10520 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00261789 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3303043 . This is a "NABP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".