Provider Demographics
NPI:1003238890
Name:ROBERTA PHARMACY LLC
Entity Type:Organization
Organization Name:ROBERTA PHARMACY LLC
Other - Org Name:ROBERTA DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-836-3515
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078-0418
Mailing Address - Country:US
Mailing Address - Phone:478-836-3515
Mailing Address - Fax:478-836-3319
Practice Address - Street 1:4 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078-4932
Practice Address - Country:US
Practice Address - Phone:478-836-3515
Practice Address - Fax:478-836-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0099873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148072AMedicaid
2145119OtherPK