Provider Demographics
NPI:1336124882
Name:PLOG, ROGER JASON
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:JASON
Last Name:PLOG
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 1:1631 154TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-6146
Mailing Address - Country:US
Mailing Address - Phone:425-747-8729
Mailing Address - Fax:
Practice Address - Street 1:653 156TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4823
Practice Address - Country:US
Practice Address - Phone:425-641-9127
Practice Address - Fax:425-641-9108
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00016310183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician