Provider Demographics
NPI:1831594902
Name:ROBERTSON, STEPHEN EZRA (PHARMD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EZRA
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 1:2310 LONGFIBRE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1513
Mailing Address - Country:US
Mailing Address - Phone:509-454-5249
Mailing Address - Fax:509-454-5246
Practice Address - Street 1:2310 LONGFIBRE AVE
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1513
Practice Address - Country:US
Practice Address - Phone:509-454-5249
Practice Address - Fax:509-454-5246
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60497079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist