Provider Demographics
NPI:1598188443
Name:ROEDER, LORES (RPH MBA)
Entity type:Individual
Prefix:
First Name:LORES
Middle Name:
Last Name:ROEDER
Suffix:
Gender:F
Credentials:RPH MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0496
Mailing Address - Country:US
Mailing Address - Phone:337-515-1508
Mailing Address - Fax:
Practice Address - Street 1:5721 ALDER ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-0496
Practice Address - Country:US
Practice Address - Phone:337-515-1508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14212183500000X
TX34262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist