Provider Demographics
NPI:1235551664
Name:LASTINE, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:LASTINE
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 1:1955 N ALANDALE AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4554
Mailing Address - Country:US
Mailing Address - Phone:520-290-6633
Mailing Address - Fax:
Practice Address - Street 1:7150 E SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-1318
Practice Address - Country:US
Practice Address - Phone:520-722-8669
Practice Address - Fax:520-722-0281
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS010488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist