Provider Demographics
NPI:1518563436
Name:ROTH, GARY (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ROTH
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 1:810 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:RARITAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08869-1112
Mailing Address - Country:US
Mailing Address - Phone:908-705-0467
Mailing Address - Fax:
Practice Address - Street 1:3166 ROUTE 22
Practice Address - Street 2:
Practice Address - City:BRANCHBURG
Practice Address - State:NJ
Practice Address - Zip Code:08876-3597
Practice Address - Country:US
Practice Address - Phone:908-704-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01986600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist