Provider Demographics
NPI:1053810390
Name:ROALES, ERNEST PAUL
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:PAUL
Last Name:ROALES
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:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:62417-0075
Mailing Address - Country:US
Mailing Address - Phone:616-945-3701
Mailing Address - Fax:618-945-9382
Practice Address - Street 1:208 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:IL
Practice Address - Zip Code:62417-1522
Practice Address - Country:US
Practice Address - Phone:618-945-3701
Practice Address - Fax:618-945-9382
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist