Provider Demographics
NPI:1932402435
Name:ROACH, JEANNIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:ROACH
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 1:21300 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4213
Mailing Address - Country:US
Mailing Address - Phone:818-884-1462
Mailing Address - Fax:818-884-4335
Practice Address - Street 1:21300 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-4213
Practice Address - Country:US
Practice Address - Phone:818-884-1462
Practice Address - Fax:818-884-4335
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist