Provider Demographics
NPI:1003584558
Name:ROBERTS, SUZANNE RUTH
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RUTH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5653 BAILEY GRANT RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8608
Mailing Address - Country:US
Mailing Address - Phone:502-558-4307
Mailing Address - Fax:
Practice Address - Street 1:5653 BAILEY GRANT RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8608
Practice Address - Country:US
Practice Address - Phone:502-558-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015289A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist