Provider Demographics
NPI:1437986791
Name:ROCK, ELIJAH ROYAL
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:ROYAL
Last Name:ROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30485 COUNTY ROAD 16
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-1006
Mailing Address - Country:US
Mailing Address - Phone:574-326-4622
Mailing Address - Fax:
Practice Address - Street 1:30485 COUNTY ROAD 16
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-1006
Practice Address - Country:US
Practice Address - Phone:574-326-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH198036183700000X
IN67043053A183700000X
30259949183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician