Provider Demographics
NPI:1841546264
Name:ROTH, SHARLA LAURENE (RPH)
Entity type:Individual
Prefix:
First Name:SHARLA
Middle Name:LAURENE
Last Name:ROTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 HAIG ST
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:NE
Mailing Address - Zip Code:69343-1716
Mailing Address - Country:US
Mailing Address - Phone:308-360-2411
Mailing Address - Fax:
Practice Address - Street 1:E HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist