Provider Demographics
NPI:1821559964
Name:ENIX, ROGER BRUCE (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BRUCE
Last Name:ENIX
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 1:3130 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4247
Mailing Address - Country:US
Mailing Address - Phone:970-247-9435
Mailing Address - Fax:
Practice Address - Street 1:3130 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4247
Practice Address - Country:US
Practice Address - Phone:970-247-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist