Provider Demographics
NPI:1154105195
Name:ROBERTSON, BRUCE WAYNE (PHARMD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:WAYNE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 BANNER WHITEHEAD RD
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:NC
Mailing Address - Zip Code:27350-9115
Mailing Address - Country:US
Mailing Address - Phone:336-250-1049
Mailing Address - Fax:
Practice Address - Street 1:10100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-3134
Practice Address - Country:US
Practice Address - Phone:336-434-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist