Provider Demographics
NPI:1750650636
Name:ROBERTS, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 ROUTE 281
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-8851
Mailing Address - Country:US
Mailing Address - Phone:607-756-8489
Mailing Address - Fax:607-756-8495
Practice Address - Street 1:3948 ROUTE 281
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-8851
Practice Address - Country:US
Practice Address - Phone:607-756-8489
Practice Address - Fax:607-756-8495
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist