Provider Demographics
NPI:1508943606
Name:DE JESUS-ROETLIN, MARIA THERESA (CLINICAL PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MARIA THERESA
Middle Name:
Last Name:DE JESUS-ROETLIN
Suffix:
Gender:F
Credentials:CLINICAL PHARMACIST
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 10
Mailing Address - Street 2:
Mailing Address - City:WELLMAN
Mailing Address - State:IA
Mailing Address - Zip Code:52356-0010
Mailing Address - Country:US
Mailing Address - Phone:319-646-3388
Mailing Address - Fax:319-646-3389
Practice Address - Street 1:221 8TH AVE
Practice Address - Street 2:
Practice Address - City:WELLMAN
Practice Address - State:IA
Practice Address - Zip Code:52356-0470
Practice Address - Country:US
Practice Address - Phone:319-646-4466
Practice Address - Fax:319-646-4477
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
420985270OtherFEDERAL ID ASSOC. MEDICAI
IA0015131Medicaid