Provider Demographics
NPI:1346262367
Name:ROEHM, JOHN MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:ROEHM
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 1:688 BALDWIN AVE
Mailing Address - Street 2:P.O. BOX 169
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-2596
Mailing Address - Country:US
Mailing Address - Phone:850-892-5612
Mailing Address - Fax:850-892-5089
Practice Address - Street 1:688 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-2596
Practice Address - Country:US
Practice Address - Phone:850-892-5612
Practice Address - Fax:850-892-5089
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH000185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104725601OtherMEDICAID DME
FL104725600Medicaid
FL104725600Medicaid