Provider Demographics
NPI:1043814015
Name:ROBERSON, JERROED DWIGHT
Entity type:Individual
Prefix:
First Name:JERROED
Middle Name:DWIGHT
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5195 LAKE RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3098
Mailing Address - Country:US
Mailing Address - Phone:972-522-0395
Mailing Address - Fax:
Practice Address - Street 1:5195 LAKE RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3098
Practice Address - Country:US
Practice Address - Phone:972-522-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist