Provider Demographics
NPI:1225752595
Name:ROBERTS, KHADIJAH AKILAH
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:AKILAH
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 1:12098 LUSHER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1302
Mailing Address - Country:US
Mailing Address - Phone:314-355-0500
Mailing Address - Fax:
Practice Address - Street 1:12098 LUSHER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1302
Practice Address - Country:US
Practice Address - Phone:314-355-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022033660183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician