Provider Demographics
NPI:1841303567
Name:ROBERTS, JOHNNY Q (DPH)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:Q
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-1600
Mailing Address - Country:US
Mailing Address - Phone:918-427-0400
Mailing Address - Fax:
Practice Address - Street 1:1016 E. RAY FINE BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954
Practice Address - Country:US
Practice Address - Phone:918-427-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist