Provider Demographics
NPI:1427658517
Name:ROACH, ROBIN EDWARD (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:EDWARD
Last Name:ROACH
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 1:1101 LAKE CHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-4104
Mailing Address - Country:US
Mailing Address - Phone:270-836-0487
Mailing Address - Fax:
Practice Address - Street 1:420 FACTORY OUTLET DR
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:KY
Practice Address - Zip Code:42413-9513
Practice Address - Country:US
Practice Address - Phone:270-440-6000
Practice Address - Fax:270-440-6010
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist