Provider Demographics
NPI:1083711634
Name:LATTA, ROGER T (R PH)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:T
Last Name:LATTA
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1412 SCOTT ST
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-1026
Practice Address - Country:US
Practice Address - Phone:419-599-9355
Practice Address - Fax:419-599-1039
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-11171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist