Provider Demographics
NPI:1699192831
Name:ROEHM, DEBRA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MARIE
Last Name:ROEHM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 OAK ST E
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-9574
Mailing Address - Country:US
Mailing Address - Phone:715-327-4208
Mailing Address - Fax:715-327-4232
Practice Address - Street 1:110 OAK ST E
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-9574
Practice Address - Country:US
Practice Address - Phone:715-327-4208
Practice Address - Fax:715-327-4232
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14493-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6220480001OtherMEDICARE PTAN