Individual
KENNETH CARLIN K.C. ROOSE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3250 E 17TH ST, AMMON, ID 83406-6758
(208) 552-7677
Mailing address
5504 CALEN LN, CHUBBUCK, ID 83202-2296
(801) 792-7902
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
P10920
ID
Other
Enumeration date
10/09/2023
Last updated
10/09/2023
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