Provider Demographics
NPI:1902958952
Name:KILLPACK, ROGER E (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:KILLPACK
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 1:215 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-9257
Mailing Address - Country:US
Mailing Address - Phone:435-864-2545
Mailing Address - Fax:435-864-5925
Practice Address - Street 1:215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-9257
Practice Address - Country:US
Practice Address - Phone:435-864-2545
Practice Address - Fax:435-864-5925
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT148723-1701183500000X
UT329033-1703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist