Provider Demographics
NPI:1396072302
Name:ESTRADA, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:ESTRADA
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 1:3911 E STATE ROUTE 69
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6717
Mailing Address - Country:US
Mailing Address - Phone:928-541-2218
Mailing Address - Fax:928-541-2257
Practice Address - Street 1:3911 E STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6717
Practice Address - Country:US
Practice Address - Phone:928-541-2218
Practice Address - Fax:928-541-2257
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist