MEDICARE: MR. CHARLES WAYNE ROETHE RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	8906-040	WI

General Provider Information

NPI Number	:	1942536016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES WAYNE ROETHE RPH

Provider Business Mailing Address
First Line	:	206 N IOWA ST
Second Line	:
City	:	DODGEVILLE
State	:	WI
Zip	:	53533-1548
Country	:	US
Telephone Number	:	608-935-3661
Fax Number	:	608-935-2661

Provider Business Practice Location Address
First Line	:	206 N IOWA ST
Second Line	:
City	:	DODGEVILLE
State	:	WI
Zip	:	53533-1548
Country	:	US
Telephone Number	:	608-935-3661
Fax Number	:	608-935-2661

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2009
Last Update Date	:	10/26/2009

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