Provider Demographics
NPI:1972736460
Name:MEDEIROS, ROLAND R (RPH)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:R
Last Name:MEDEIROS
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 1:184 MARION OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-2205
Mailing Address - Country:US
Mailing Address - Phone:352-347-3115
Mailing Address - Fax:352-347-1329
Practice Address - Street 1:184 MARION OAKS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-2205
Practice Address - Country:US
Practice Address - Phone:352-347-3115
Practice Address - Fax:352-347-1329
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL020491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10278101Medicaid
FL10278101Medicaid