Provider Demographics
NPI:1417085762
Name:ROGERS, PETRA DIANA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:DIANA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 19TH AVE
Mailing Address - Street 2:RITE AID PHARMACY #5408
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4069
Mailing Address - Country:US
Mailing Address - Phone:208-743-9127
Mailing Address - Fax:208-743-4777
Practice Address - Street 1:1904 19TH AVE
Practice Address - Street 2:RITE AID PHARMACY #5408
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4069
Practice Address - Country:US
Practice Address - Phone:208-743-9127
Practice Address - Fax:208-743-4777
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5732183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist