Provider Demographics
NPI:1942802343
Name:ROBERTS, TRACY D
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 KELLER CT
Mailing Address - Street 2:
Mailing Address - City:ROYAL
Mailing Address - State:AR
Mailing Address - Zip Code:71968-9748
Mailing Address - Country:US
Mailing Address - Phone:501-617-6923
Mailing Address - Fax:
Practice Address - Street 1:2001 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8124
Practice Address - Country:US
Practice Address - Phone:870-722-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist