Provider Demographics
NPI:1639223001
Name:ROAN, PAUL MICHAEL (BS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:ROAN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:PA
Mailing Address - Zip Code:18651-3018
Mailing Address - Country:US
Mailing Address - Phone:570-779-9503
Mailing Address - Fax:570-779-4889
Practice Address - Street 1:159 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:PA
Practice Address - Zip Code:18651-3018
Practice Address - Country:US
Practice Address - Phone:570-779-9503
Practice Address - Fax:570-779-4889
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP031551L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist