Provider Demographics
NPI:1891399945
Name:ROBERTSON, TIMOTHY R (RPH)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:ROBERTSON
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 1:15 DILLARD LN
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-2401
Mailing Address - Country:US
Mailing Address - Phone:540-580-5289
Mailing Address - Fax:
Practice Address - Street 1:400 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-4394
Practice Address - Country:US
Practice Address - Phone:276-629-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist