Provider Demographics
NPI:1407449382
Name:ROBERSON, STEVIE JOE (RPH)
Entity Type:Individual
Prefix:
First Name:STEVIE
Middle Name:JOE
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-0787
Mailing Address - Country:US
Mailing Address - Phone:318-465-7170
Mailing Address - Fax:
Practice Address - Street 1:929 S PINE ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3364
Practice Address - Country:US
Practice Address - Phone:318-375-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist