Provider Demographics
NPI:1841568656
Name:ROBERTSON, JOE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 JORDAN RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-8268
Mailing Address - Country:US
Mailing Address - Phone:601-498-7866
Mailing Address - Fax:
Practice Address - Street 1:804 SPRING ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2422
Practice Address - Country:US
Practice Address - Phone:601-735-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-09199OtherPHARMACY BOARD