Provider Demographics
NPI:1053683144
Name:ROTH, JEANNE MARIE
Entity Type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8410 FARM RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-8158
Mailing Address - Country:US
Mailing Address - Phone:702-658-6669
Mailing Address - Fax:702-658-7987
Practice Address - Street 1:8410 FARM RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-8158
Practice Address - Country:US
Practice Address - Phone:702-658-6669
Practice Address - Fax:702-658-7987
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist