Provider Demographics
NPI:1871961870
Name:ROBERTS, JOHN HARLEY
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HARLEY
Last Name:ROBERTS
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 1:2001 GLENN BLVD SW
Mailing Address - Street 2:
Mailing Address - City:FT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968
Mailing Address - Country:US
Mailing Address - Phone:256-997-1194
Mailing Address - Fax:256-997-1196
Practice Address - Street 1:2001 GLENN BLVD SW
Practice Address - Street 2:
Practice Address - City:FT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968
Practice Address - Country:US
Practice Address - Phone:256-997-1194
Practice Address - Fax:256-997-1196
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist