Provider Demographics
NPI:1942557244
Name:ROTH, TERRY L (RPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:ROTH
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 1:2330 HIGHWAY 93 NORTH
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-758-2528
Mailing Address - Fax:406-758-2525
Practice Address - Street 1:2330 HWY 93 N
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-758-2528
Practice Address - Fax:406-758-2525
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist