Provider Demographics
NPI:1174857080
Name:ROEING, JASON ALAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:ROEING
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 WHITE HORSE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9540
Mailing Address - Country:US
Mailing Address - Phone:336-545-4460
Mailing Address - Fax:
Practice Address - Street 1:1701 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704
Practice Address - Country:US
Practice Address - Phone:309-662-7004
Practice Address - Fax:309-662-6650
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0418298Medicaid