Provider Demographics
NPI:1588996755
Name:ROTH, STANLEY RAYMOND (RPH)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:RAYMOND
Last Name:ROTH
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 1:1111 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3905
Mailing Address - Country:US
Mailing Address - Phone:218-326-0593
Mailing Address - Fax:
Practice Address - Street 1:1111 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3905
Practice Address - Country:US
Practice Address - Phone:218-326-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115997183500000X
SD3743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist