Provider Demographics
NPI:1578862942
Name:ROBERTS, CHARLES LOGAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LOGAN
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 1:1655 ZEBULON RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-5155
Mailing Address - Country:US
Mailing Address - Phone:770-228-5009
Mailing Address - Fax:770-228-9013
Practice Address - Street 1:1655 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-5155
Practice Address - Country:US
Practice Address - Phone:770-228-5009
Practice Address - Fax:770-228-9013
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist