1346243672 NPI number — ERNEST & SUSAN L ROALES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346243672 NPI number — ERNEST & SUSAN L ROALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERNEST & SUSAN L ROALES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SCOTTS DRUGS
Provider Other Organization Name Type Code:
3
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:
1346243672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 75
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62417-0075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-945-3701
Provider Business Mailing Address Fax Number:
618-945-9382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62417-1522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-945-3701
Provider Business Practice Location Address Fax Number:
618-945-3701
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROALES
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-945-3701

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054008755 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2018808 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com