Provider Demographics
NPI:1124329651
Name:ROBERTSON, RICHARD BYRON (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BYRON
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 1:2330 NEZ PERCE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4107
Mailing Address - Country:US
Mailing Address - Phone:208-798-0481
Mailing Address - Fax:208-798-0715
Practice Address - Street 1:2330 NEZ PERCE DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4107
Practice Address - Country:US
Practice Address - Phone:208-798-0481
Practice Address - Fax:208-798-0715
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-4526183500000X
WAPH 00009240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP-4526OtherIDAHO PHARMACIST LICENSE