Healthcare Provider Details

I. General information

NPI: 1710403316
Provider Name (Legal Business Name): LAUREN ROOF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 99TH AVE
TOLLESON AZ
85353-9700
US

IV. Provider business mailing address

455 S RECKER RD APT 2046
GILBERT AZ
85296-1216
US

V. Phone/Fax

Practice location:
  • Phone: 623-936-2363
  • Fax:
Mailing address:
  • Phone: 803-397-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS023005
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberS023005
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: