Provider Demographics
NPI:1578724860
Name:ROBERTS PHARMACY LLC
Entity Type:Organization
Organization Name:ROBERTS PHARMACY LLC
Other - Org Name:EUREKA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-583-5488
Mailing Address - Street 1:1602 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:KS
Mailing Address - Zip Code:67045-1090
Mailing Address - Country:US
Mailing Address - Phone:620-583-5488
Mailing Address - Fax:620-583-6495
Practice Address - Street 1:1602 N ELM ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:KS
Practice Address - Zip Code:67045-1090
Practice Address - Country:US
Practice Address - Phone:620-583-5488
Practice Address - Fax:620-583-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-10113333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200542310AMedicaid