Provider Demographics
NPI:1477862480
Name:QUEEN, ROGER WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WAYNE
Last Name:QUEEN
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 1:1123 KILDAIRE FARM RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4522
Mailing Address - Country:US
Mailing Address - Phone:919-467-5572
Mailing Address - Fax:919-380-7568
Practice Address - Street 1:1123 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4522
Practice Address - Country:US
Practice Address - Phone:919-467-5572
Practice Address - Fax:919-380-7568
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2010-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7634183500000X
VA5205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist