Provider Demographics
NPI:1053711705
Name:ROBERTS, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ROBERTS
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 1:1159 E US HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-6837
Mailing Address - Country:US
Mailing Address - Phone:573-346-4155
Mailing Address - Fax:
Practice Address - Street 1:1159 E US HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-6837
Practice Address - Country:US
Practice Address - Phone:573-346-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist