Provider Demographics
NPI:1679746291
Name:SMITH, ROGER (RPH)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 BRECKSVILLE RD # 119B
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3204
Mailing Address - Country:US
Mailing Address - Phone:440-526-3030
Mailing Address - Fax:440-717-2844
Practice Address - Street 1:10000 BRECKSVILLE RD # 119B
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:440-717-2844
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-24699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist