Provider Demographics
NPI:1790009314
Name:ALLEN, ROGER W (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:M
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:PO BOX 31084
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85275-1084
Mailing Address - Country:US
Mailing Address - Phone:480-200-2479
Mailing Address - Fax:
Practice Address - Street 1:2344 E BASELINE RD # 4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6959
Practice Address - Country:US
Practice Address - Phone:480-200-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist