Provider Demographics
NPI:1578361218
Name:ROBERTS, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2717
Mailing Address - Country:US
Mailing Address - Phone:573-694-1314
Mailing Address - Fax:
Practice Address - Street 1:3501 W TRUMAN BLVD STE H
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0514
Practice Address - Country:US
Practice Address - Phone:573-556-5551
Practice Address - Fax:573-556-5552
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist