Provider Demographics
NPI:1063045425
Name:ROBERTS, JUSTIN RYAN (RPH)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RYAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 S NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1002
Mailing Address - Country:US
Mailing Address - Phone:248-728-6500
Mailing Address - Fax:
Practice Address - Street 1:2950 S NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1002
Practice Address - Country:US
Practice Address - Phone:734-728-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist