Provider Demographics
NPI:1518503614
Name:ROBERTS, SAMUEL PAUL (RPH)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PAUL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 W LAKE POTOMAC VW APT G
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-7359
Mailing Address - Country:US
Mailing Address - Phone:317-657-0153
Mailing Address - Fax:
Practice Address - Street 1:1571 N STATE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1066
Practice Address - Country:US
Practice Address - Phone:317-467-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-23
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028300A183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist