Provider Demographics
NPI:1669970281
Name:TEAGUE, ROGER ALAN
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ALAN
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 GUTHRIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5507
Mailing Address - Country:US
Mailing Address - Phone:931-552-4602
Mailing Address - Fax:931-552-4715
Practice Address - Street 1:3315 GUTHRIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5507
Practice Address - Country:US
Practice Address - Phone:931-552-4602
Practice Address - Fax:931-552-4715
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN593872OtherNABP