Provider Demographics
NPI:1881170868
Name:ROLL, MADELINE KEIKO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:KEIKO
Last Name:ROLL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E NIFONG BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3760
Mailing Address - Country:US
Mailing Address - Phone:573-442-2951
Mailing Address - Fax:
Practice Address - Street 1:205 E NIFONG BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3760
Practice Address - Country:US
Practice Address - Phone:573-442-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist