Provider Demographics
NPI:1861456832
Name:ROBERTS, BRENT (RPH)
Entity Type:Individual
Prefix:
First Name:BRENT
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 1:205 S CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-4012
Mailing Address - Country:US
Mailing Address - Phone:620-241-0941
Mailing Address - Fax:
Practice Address - Street 1:205 S CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-4012
Practice Address - Country:US
Practice Address - Phone:620-241-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00530363AM0700X
KS10916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100377720AMedicaid
KS042350Medicare ID - Type UnspecifiedMEDICARE INDIV NUMBER
OTH000Medicare UPIN