Provider Demographics
NPI:1083064836
Name:ROBERTS, CHARLES II
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ROBERTS
Suffix:II
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 1:597 DONALD C. MOORE DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:597 DONALD C. MOORE DRIVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-254-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210749183500000X
TN0000036205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist