Provider Demographics
NPI:1275047599
Name:ROTH, SIMEON P (RPH)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:P
Last Name:ROTH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:SULTAN
Mailing Address - State:WA
Mailing Address - Zip Code:98294-0090
Mailing Address - Country:US
Mailing Address - Phone:360-953-5250
Mailing Address - Fax:
Practice Address - Street 1:31111 US 2
Practice Address - Street 2:
Practice Address - City:SULTAN
Practice Address - State:WA
Practice Address - Zip Code:98294-0090
Practice Address - Country:US
Practice Address - Phone:360-953-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60757022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60757022OtherPHARMACIST LICENSE
WA2132773Medicaid