Provider Demographics
NPI:1578916706
Name:ROBERTSON, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SUMMER PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4707
Mailing Address - Country:US
Mailing Address - Phone:207-409-4135
Mailing Address - Fax:207-795-7552
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7676
Practice Address - Country:US
Practice Address - Phone:207-795-7552
Practice Address - Fax:207-795-7552
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist