Provider Demographics
NPI:1528201340
Name:ROBERTS SOUTH BANK PHARMACY INC
Entity Type:Organization
Organization Name:ROBERTS SOUTH BANK PHARMACY INC
Other - Org Name:ROBERTS' SOUTH BANK PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-398-9660
Mailing Address - Street 1:1625 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3318
Mailing Address - Country:US
Mailing Address - Phone:904-398-9660
Mailing Address - Fax:904-398-9662
Practice Address - Street 1:1625 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3318
Practice Address - Country:US
Practice Address - Phone:904-398-9660
Practice Address - Fax:904-398-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH240063336C0003X
FLPH 240063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119961OtherPK