Provider Demographics
NPI:1467438960
Name:ROTH, WILLIAM J
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:ROTH
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:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:SD
Mailing Address - Zip Code:57058-0316
Mailing Address - Country:US
Mailing Address - Phone:605-425-2827
Mailing Address - Fax:605-425-2052
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:SD
Practice Address - Zip Code:57058
Practice Address - Country:US
Practice Address - Phone:605-425-2827
Practice Address - Fax:605-425-2052
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8502580Medicaid
SD8502580Medicaid