Provider Demographics
NPI:1083214209
Name:ROTH, KELLY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
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 1:1 LAUREN LN
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:NJ
Mailing Address - Zip Code:07461-4116
Mailing Address - Country:US
Mailing Address - Phone:973-537-9743
Mailing Address - Fax:
Practice Address - Street 1:230 ROUTE 23
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NJ
Practice Address - Zip Code:07416-2008
Practice Address - Country:US
Practice Address - Phone:973-209-4253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03586900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist