Provider Demographics
NPI:1508349465
Name:ROBERTS, MILES DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:DAVID
Last Name:ROBERTS
Suffix:
Gender:M
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:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-0853
Mailing Address - Country:US
Mailing Address - Phone:801-824-7684
Mailing Address - Fax:
Practice Address - Street 1:2111 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3329
Practice Address - Country:US
Practice Address - Phone:503-338-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10120119-8911183500000X
UT10120119-1701183500000X
ORRPH0016834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10120119-8911OtherDIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING CONTROLLED SUBSTANCE LICENSE
UT10120119-1701OtherDIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING PHARMACIST LICENSE
ORRPH0016834OtherOREGON BOARD OF PHARMACY PHARMACIST LICENSE