Provider Demographics
NPI:1801491790
Name:ROBERTSON, BRENT ADAM
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ADAM
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:OIL CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16301-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 E 2ND ST
Practice Address - Street 2:
Practice Address - City:OIL CITY
Practice Address - State:PA
Practice Address - Zip Code:16301-2321
Practice Address - Country:US
Practice Address - Phone:814-677-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03331269OtherPHARMACY LICENSE
PARP441900OtherPHARMACY LICENSE