Healthcare Provider Details

I. General information

NPI: 1811205271
Provider Name (Legal Business Name): ROBERTS DRUG STORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 03/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W TRUMAN BLVD SUITE H
JEFFERSON CITY MO
65109-5715
US

IV. Provider business mailing address

3501 W TRUMAN BLVD SUITE H
JEFFERSON CITY MO
65109-5715
US

V. Phone/Fax

Practice location:
  • Phone: 573-556-5551
  • Fax: 573-556-5552
Mailing address:
  • Phone: 573-556-5551
  • Fax: 573-556-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2018007651
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number2018007651
License Number StateMO

VIII. Authorized Official

Name: MRS. KIMBERLY ANN ROBERTS
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 573-821-2438