Provider Demographics
NPI:1326519521
Name:ROERECKE, SUSAN AVERITTE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:AVERITTE
Last Name:ROERECKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3999
Mailing Address - Country:US
Mailing Address - Phone:903-758-6164
Mailing Address - Fax:
Practice Address - Street 1:110 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-3999
Practice Address - Country:US
Practice Address - Phone:903-758-6164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist