Provider Demographics
NPI:1659776748
Name:ROBERTSON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
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 1:2727 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MI
Mailing Address - Zip Code:48063-4221
Mailing Address - Country:US
Mailing Address - Phone:810-305-1045
Mailing Address - Fax:
Practice Address - Street 1:2727 CHURCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MI
Practice Address - Zip Code:48063-4221
Practice Address - Country:US
Practice Address - Phone:810-305-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302026336OtherPHARMACIST LICENSE