Provider Demographics
NPI:1609114909
Name:ROBERTS, RICK THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:THOMAS
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24029 MADACA LN
Mailing Address - Street 2:APT 104
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-2815
Mailing Address - Country:US
Mailing Address - Phone:215-589-5748
Mailing Address - Fax:
Practice Address - Street 1:24123 PEACHLAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-3774
Practice Address - Country:US
Practice Address - Phone:941-627-5704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48695183500000X
PARP445982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS48695OtherPHARMACIST LICENSE FL