Provider Demographics
NPI:1811205271
Name:ROBERTS DRUG STORE, LLC
Entity type:Organization
Organization Name:ROBERTS DRUG STORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-821-2438
Mailing Address - Street 1:3501 W TRUMAN BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5715
Mailing Address - Country:US
Mailing Address - Phone:573-556-5551
Mailing Address - Fax:573-556-5552
Practice Address - Street 1:3501 W TRUMAN BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5715
Practice Address - Country:US
Practice Address - Phone:573-556-5551
Practice Address - Fax:573-556-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180076513336L0003X, 3336C0003X
MO2010035928333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606488302Medicaid