MEDICARE: DR. JACQUENITA MARIE ROBERTSON PHARM.D

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	54002	TX

General Provider Information

NPI Number	:	1306275664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUENITA MARIE ROBERTSON PHARM.D

Provider Business Mailing Address
First Line	:	6130 NEWTON DR
Second Line	:	APT 4309
City	:	FT WORTH
State	:	TX
Zip	:	76132-5302
Country	:	US
Telephone Number	:	254-368-3322
Fax Number	:

Provider Business Practice Location Address
First Line	:	6130 NEWTON DR
Second Line	:	APT 4309
City	:	FT WORTH
State	:	TX
Zip	:	76132-5302
Country	:	US
Telephone Number	:	254-368-3322
Fax Number	:

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

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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