MEDICARE: MR. IVAN ROBERTSON P.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	PST.016241	LA

General Provider Information

NPI Number	:	1821342726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IVAN ROBERTSON P.D.

Provider Business Mailing Address
First Line	:	PO BOX 2668
Second Line	:
City	:	SAINT FRANCISVILLE
State	:	LA
Zip	:	70775-2668
Country	:	US
Telephone Number	:	225-635-3885
Fax Number	:	225-635-0290

Provider Business Practice Location Address
First Line	:	7139 U S HWY 61
Second Line	:
City	:	SAINT FRANCISVILLE
State	:	LA
Zip	:	70775-7139
Country	:	US
Telephone Number	:	225-635-3885
Fax Number	:	225-635-0290

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

Provider Enumeration Date	:	10/31/2012
Last Update Date	:	10/31/2012

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