Healthcare Provider Details

I. General information

NPI: 1386962405
Provider Name (Legal Business Name): JACQUELINE MARIE ROBERTS RPH, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 OLD FARMS RD
SOUTH GLASTONBURY CT
06073-3712
US

IV. Provider business mailing address

67 OLD FARMS RD
SOUTH GLASTONBURY CT
06073-3712
US

V. Phone/Fax

Practice location:
  • Phone: 860-633-2012
  • Fax:
Mailing address:
  • Phone: 860-633-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0008290
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23140
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: