Provider Demographics
NPI:1508012642
Name:ROTHBERG, MARC MATTHEW (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:MATTHEW
Last Name:ROTHBERG
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 1:180 GLENEIDA AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-1211
Mailing Address - Country:US
Mailing Address - Phone:845-225-1038
Mailing Address - Fax:845-228-0257
Practice Address - Street 1:180 GLENEIDA AVENUE
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-1211
Practice Address - Country:US
Practice Address - Phone:845-225-1038
Practice Address - Fax:845-228-0257
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031010-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031010-1OtherSTATE PHARMACY LICENSE