Provider Demographics
NPI:1407825177
Name:ROTH, BERNADEANE B (PHARM D)
Entity Type:Individual
Prefix:
First Name:BERNADEANE
Middle Name:B
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:BERNI, BERNIE
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:133 CANVASBACK RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-9040
Mailing Address - Country:US
Mailing Address - Phone:307-672-5341
Mailing Address - Fax:
Practice Address - Street 1:1333 W 5TH ST
Practice Address - Street 2:STE. 107
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-673-3188
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY2959OtherWYOMING PHARMACY LICENSE