Provider Demographics
NPI:1740960939
Name:ROBERTSON BRUNSWIG, JENA
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:ROBERTSON BRUNSWIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ALBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67871-6122
Mailing Address - Country:US
Mailing Address - Phone:620-376-8812
Mailing Address - Fax:
Practice Address - Street 1:102 ALBERT AVE
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:KS
Practice Address - Zip Code:67871-7102
Practice Address - Country:US
Practice Address - Phone:620-872-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist