Provider Demographics
NPI:1972783496
Name:ROBERTS, PHELICISIMA WEAVER (RPH, PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:PHELICISIMA
Middle Name:WEAVER
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 LONG RIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4370
Mailing Address - Country:US
Mailing Address - Phone:502-254-3219
Mailing Address - Fax:
Practice Address - Street 1:12501 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1530
Practice Address - Country:US
Practice Address - Phone:502-244-7961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist