Healthcare Provider Details

I. General information

NPI: 1912289877
Provider Name (Legal Business Name): KYUNGMI ROKA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 WILLOWHILL LN
TOLEDO OH
43615
US

IV. Provider business mailing address

2110 WILLOWHILL LN
TOLEDO OH
43615-3748
US

V. Phone/Fax

Practice location:
  • Phone: 419-699-8411
  • Fax:
Mailing address:
  • Phone: 419-699-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03122725
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302032833
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: