Provider Demographics
NPI:1013316462
Name:SMITH, ROBERT MERVIN (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MERVIN
Last Name:SMITH
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 1:503 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2203
Mailing Address - Country:US
Mailing Address - Phone:618-565-2329
Mailing Address - Fax:618-565-2430
Practice Address - Street 1:503 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2203
Practice Address - Country:US
Practice Address - Phone:618-565-2329
Practice Address - Fax:618-565-2430
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510317981835P1200X
MO0297691835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy