Provider Demographics
NPI:1902087752
Name:ROTH, MICHELLE AGNIESZKA (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:AGNIESZKA
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DYKEMAN RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-5044
Mailing Address - Country:US
Mailing Address - Phone:845-225-3262
Mailing Address - Fax:
Practice Address - Street 1:1490 ROUTE 9
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4116
Practice Address - Country:US
Practice Address - Phone:845-297-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist