Provider Demographics
NPI:1225627060
Name:ROACH, JOE
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 HIGHWAY 63B STE A
Mailing Address - Street 2:
Mailing Address - City:MARKED TREE
Mailing Address - State:AR
Mailing Address - Zip Code:72365-1614
Mailing Address - Country:US
Mailing Address - Phone:870-351-5022
Mailing Address - Fax:
Practice Address - Street 1:98 HIGHWAY 63B STE A
Practice Address - Street 2:
Practice Address - City:MARKED TREE
Practice Address - State:AR
Practice Address - Zip Code:72365-1614
Practice Address - Country:US
Practice Address - Phone:870-351-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty