Provider Demographics
NPI:1821342726
Name:ROBERTSON, IVAN (PD)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2668
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-2668
Mailing Address - Country:US
Mailing Address - Phone:225-635-3885
Mailing Address - Fax:225-635-0290
Practice Address - Street 1:7139 U S HWY 61
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775-7139
Practice Address - Country:US
Practice Address - Phone:225-635-3885
Practice Address - Fax:225-635-0290
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.016241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist