Provider Demographics
NPI:1962782201
Name:HOUSTON, ROGER DALE
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:HOUSTON
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 1:6112 GANNETWOORD PLACE
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547
Mailing Address - Country:US
Mailing Address - Phone:813-385-0155
Mailing Address - Fax:
Practice Address - Street 1:6112 GANNETWOORD PLACE
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547
Practice Address - Country:US
Practice Address - Phone:813-385-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI21830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21830OtherPHARMACY LICENSE NUMBER