Provider Demographics
NPI:1407363815
Name:ROARK, BRIAN DOUGLAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:ROARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 HEMLOCK LN
Mailing Address - Street 2:
Mailing Address - City:BLACKEY
Mailing Address - State:KY
Mailing Address - Zip Code:41804-8741
Mailing Address - Country:US
Mailing Address - Phone:502-381-8152
Mailing Address - Fax:
Practice Address - Street 1:59 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9631
Practice Address - Country:US
Practice Address - Phone:606-666-2883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist