Provider Demographics
NPI:1811552490
Name:ROBERTS, CAMILLE SHOFNER
Entity Type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:SHOFNER
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CAMILLE
Other - Middle Name:RUTLEDGE
Other - Last Name:SHOFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:149 SHERLOCK HERRING RD
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-3145
Mailing Address - Country:US
Mailing Address - Phone:601-466-7930
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-4213
Practice Address - Fax:601-288-4163
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist