Provider Demographics
NPI:1023628773
Name:ROELL, STEPHEN CLARENCE (RPH)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:CLARENCE
Last Name:ROELL
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:P. O. BOX 189
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-774-3654
Mailing Address - Fax:906-774-6833
Practice Address - Street 1:1112 S. STEPHENSON AVE.
Practice Address - Street 2:MIDTOWN MALL
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-774-3654
Practice Address - Fax:906-774-6833
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020263371835N1003X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support