Provider Demographics
NPI:1912359258
Name:LOPEZ, ROGELIO (RPH)
Entity Type:Individual
Prefix:
First Name:ROGELIO
Middle Name:
Last Name:LOPEZ
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 1:1128 NE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4853
Mailing Address - Country:US
Mailing Address - Phone:786-489-1760
Mailing Address - Fax:
Practice Address - Street 1:1128 NE 16TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-4853
Practice Address - Country:US
Practice Address - Phone:786-489-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 27413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist