Provider Demographics
NPI:1922170166
Name:ROARK, MARY ANN (DPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:ROARK
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19118 ALBERTA ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:TN
Mailing Address - Zip Code:37841-6003
Mailing Address - Country:US
Mailing Address - Phone:423-569-9000
Mailing Address - Fax:423-569-2402
Practice Address - Street 1:19118 ALBERTA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841-6003
Practice Address - Country:US
Practice Address - Phone:423-569-9000
Practice Address - Fax:423-569-2402
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7478183500000X
KY010025183500000X
FLPS 19818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7478OtherPHARMACIST LIC NUMBER