Provider Demographics
NPI:1225183973
Name:WATKINS, ROGER E (04764)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:WATKINS
Suffix:
Gender:M
Credentials:04764
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9409 REVELL RD
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-9203
Mailing Address - Country:US
Mailing Address - Phone:919-284-2182
Mailing Address - Fax:
Practice Address - Street 1:110 W SECOND ST
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542-0235
Practice Address - Country:US
Practice Address - Phone:919-284-2010
Practice Address - Fax:919-284-2231
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC04764183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0515221Medicaid