Provider Demographics
NPI:1891395273
Name:ROE, ANDREA WADE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:WADE
Last Name:ROE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 CHERRY BLOSSOM WAY # WAY7
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9564
Mailing Address - Country:US
Mailing Address - Phone:502-570-4608
Mailing Address - Fax:502-570-4610
Practice Address - Street 1:1001 CHERRY BLOSSOM WAY # WAY7
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9564
Practice Address - Country:US
Practice Address - Phone:502-570-4608
Practice Address - Fax:502-570-4610
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist