Healthcare Provider Details

I. General information

NPI: 1902716582
Provider Name (Legal Business Name): JOHN A ROBERTS VA61149063
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 NE 162ND AVE
VANCOU WA
98671
US

IV. Provider business mailing address

2800 NE 162ND AVE
VANCOU WA
98671
US

V. Phone/Fax

Practice location:
  • Phone: 360-433-7535
  • Fax: 360-253-5622
Mailing address:
  • Phone: 360-433-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA61149063
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: