Provider Demographics
NPI:1003589946
Name:ROTH, PETER HAYDEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HAYDEN
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5745 ERIC CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-3521
Mailing Address - Country:US
Mailing Address - Phone:920-207-7677
Mailing Address - Fax:
Practice Address - Street 1:401 E GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2541
Practice Address - Country:US
Practice Address - Phone:715-524-5600
Practice Address - Fax:715-524-5050
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21034-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist