Provider Demographics
NPI:1295196129
Name:ROTH, RICHARD (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
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 1:519 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1526
Mailing Address - Country:US
Mailing Address - Phone:860-388-1045
Mailing Address - Fax:860-395-2412
Practice Address - Street 1:519 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1526
Practice Address - Country:US
Practice Address - Phone:860-388-1045
Practice Address - Fax:860-395-2412
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist