Provider Demographics
NPI:1114359510
Name:ROBERTS, DOROTHY ELAINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ELAINE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6717
Mailing Address - Country:US
Mailing Address - Phone:208-522-4824
Mailing Address - Fax:208-523-6830
Practice Address - Street 1:3101 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6717
Practice Address - Country:US
Practice Address - Phone:208-522-4824
Practice Address - Fax:208-523-6830
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist