Provider Demographics
NPI:1063015907
Name:OVERTON, ROGER ERIC (RPH)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ERIC
Last Name:OVERTON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8224
Mailing Address - Country:US
Mailing Address - Phone:608-788-9146
Mailing Address - Fax:608-788-9144
Practice Address - Street 1:4622 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8224
Practice Address - Country:US
Practice Address - Phone:608-788-9146
Practice Address - Fax:608-788-9144
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14105-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist