Provider Demographics
NPI:1558490482
Name:ROBERTSON, DETRA LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DETRA
Middle Name:LYNN
Last Name:ROBERTSON
Suffix:
Gender:F
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 4298
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-4298
Mailing Address - Country:US
Mailing Address - Phone:865-585-1136
Mailing Address - Fax:
Practice Address - Street 1:915 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6633
Practice Address - Country:US
Practice Address - Phone:423-626-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist