Provider Demographics
NPI:1942536016
Name:ROETHE, CHARLES WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WAYNE
Last Name:ROETHE
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 1:206 N IOWA ST
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-1548
Mailing Address - Country:US
Mailing Address - Phone:608-935-3661
Mailing Address - Fax:608-935-2661
Practice Address - Street 1:206 N IOWA ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1548
Practice Address - Country:US
Practice Address - Phone:608-935-3661
Practice Address - Fax:608-935-2661
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8906-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist