Provider Demographics
NPI:1013510536
Name:ROBERTSON, JOHN LEVER (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEVER
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 1:3950 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4648
Mailing Address - Country:US
Mailing Address - Phone:270-519-4944
Mailing Address - Fax:
Practice Address - Street 1:538 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4538
Practice Address - Country:US
Practice Address - Phone:270-443-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY008562OtherPHARMACIST LICENSE