Provider Demographics
NPI:1508156621
Name:ROBERTS, BERNICE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 AUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3221
Mailing Address - Country:US
Mailing Address - Phone:404-219-5605
Mailing Address - Fax:678-583-1257
Practice Address - Street 1:2125 HIGHWAY 155 N
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-4809
Practice Address - Country:US
Practice Address - Phone:678-583-5592
Practice Address - Fax:678-583-1257
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH012704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist