Provider Demographics
NPI:1952437998
Name:MCKELVEY, ROGER L
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:MCKELVEY
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 1:233 TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-9315
Mailing Address - Country:US
Mailing Address - Phone:419-636-4180
Mailing Address - Fax:
Practice Address - Street 1:618 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1609
Practice Address - Country:US
Practice Address - Phone:419-782-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-17640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist