Provider Demographics
NPI:1538422530
Name:ROACH, ALYSIA (PHARMD)
Entity type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
Last Name:ROACH
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 1:1009 CALLE ROSA PL
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6601
Mailing Address - Country:US
Mailing Address - Phone:813-634-7985
Mailing Address - Fax:
Practice Address - Street 1:10150 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3612
Practice Address - Country:US
Practice Address - Phone:813-387-1162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31289183500000X
NC16255183500000X
TX42202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist