Provider Demographics
NPI:1508490178
Name:MORTEMORE, ROGER JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:JAMES
Last Name:MORTEMORE
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 1:1375 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2101
Mailing Address - Country:US
Mailing Address - Phone:317-253-6427
Mailing Address - Fax:
Practice Address - Street 1:1375 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2101
Practice Address - Country:US
Practice Address - Phone:317-253-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-23
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017645A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist