Provider Demographics
NPI:1932796273
Name:ROTH, KALEB
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:ROTH
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 1:7504 N 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1678
Mailing Address - Country:US
Mailing Address - Phone:712-661-9577
Mailing Address - Fax:
Practice Address - Street 1:1250 LAKE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1997
Practice Address - Country:US
Practice Address - Phone:712-732-1364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist