Healthcare Provider Details

I. General information

NPI: 1598877441
Provider Name (Legal Business Name): ROBERTS PBA DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 8TH ST
BALDWIN CITY KS
66006-4149
US

IV. Provider business mailing address

PO BOX 71
BALDWIN CITY KS
66006-0071
US

V. Phone/Fax

Practice location:
  • Phone: 785-594-6867
  • Fax: 785-594-3883
Mailing address:
  • Phone: 785-594-6711
  • Fax: 785-594-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number209755
License Number StateKS

VIII. Authorized Official

Name: GARY ROBERTS
Title or Position: OWNER
Credential:
Phone: 785-594-6711