Provider Demographics
NPI:1598877441
Name:ROBERTS PBA DRUG STORE
Entity Type:Organization
Organization Name:ROBERTS PBA DRUG STORE
Other - Org Name:ROBERTS PBA DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-594-6711
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:BALDWIN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66006-0071
Mailing Address - Country:US
Mailing Address - Phone:785-594-6711
Mailing Address - Fax:785-594-3883
Practice Address - Street 1:112 8TH ST
Practice Address - Street 2:
Practice Address - City:BALDWIN CITY
Practice Address - State:KS
Practice Address - Zip Code:66006-4149
Practice Address - Country:US
Practice Address - Phone:785-594-6867
Practice Address - Fax:785-594-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KS2097553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100443660AMedicaid
2030679OtherPK