Provider Demographics
NPI:1710902531
Name:ROBERTS PHARMACY INC
Entity Type:Organization
Organization Name:ROBERTS PHARMACY INC
Other - Org Name:VITAL CARE OF SOUTHWEST GEORGIA, DONALSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-524-2313
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:803 N WILEY AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1121
Practice Address - Country:US
Practice Address - Phone:229-524-2313
Practice Address - Fax:229-524-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE004506332B00000X, 332BP3500X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00035153BMedicaid
GA277634OtherBCBS
GA277634OtherBCBS
GA277634OtherBCBS
=========002OtherTRICARE CSP