Provider Demographics
NPI:1326141375
Name:ROBERTS PHARMACY INC
Entity Type:Organization
Organization Name:ROBERTS PHARMACY INC
Other - Org Name:ROBERTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STORE MANG/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RATHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-524-2313
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-0157
Mailing Address - Country:US
Mailing Address - Phone:229-524-2313
Mailing Address - Fax:229-524-1202
Practice Address - Street 1:803 N WILEY AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1121
Practice Address - Country:US
Practice Address - Phone:229-524-2313
Practice Address - Fax:229-524-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336H0001X, 3336L0003X
GAPHRE0045063336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000035153AMedicaid
2012326OtherPK
GA000035153AMedicaid