Provider Demographics
NPI:1073114880
Name:ROETTENBACHER, LAWRENCE (RPH)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:ROETTENBACHER
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 1:3560 ROUTE 611 STE 105
Mailing Address - Street 2:
Mailing Address - City:BARTONSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18321-9452
Mailing Address - Country:US
Mailing Address - Phone:570-421-2896
Mailing Address - Fax:
Practice Address - Street 1:3560 ROUTE 611 STE 105
Practice Address - Street 2:
Practice Address - City:BARTONSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18321-9452
Practice Address - Country:US
Practice Address - Phone:570-421-2896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP032486L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist