Provider Demographics
NPI:1275811929
Name:RODERICK, CLINT IV (RPH)
Entity Type:Individual
Prefix:MR
First Name:CLINT
Middle Name:
Last Name:RODERICK
Suffix:IV
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 1:306 RUMFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-9012
Mailing Address - Country:US
Mailing Address - Phone:717-578-2627
Mailing Address - Fax:
Practice Address - Street 1:912 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3700
Practice Address - Country:US
Practice Address - Phone:717-741-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP038439L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP038439LOtherPA PHARMACIST LICENSE