Provider Demographics
NPI:1063557791
Name:ROBERTS, CULLIE TAYLOR JR (RPH)
Entity type:Individual
Prefix:
First Name:CULLIE
Middle Name:TAYLOR
Last Name:ROBERTS
Suffix:JR
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 1:1005 ROSEMARY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2073
Mailing Address - Country:US
Mailing Address - Phone:662-843-3416
Mailing Address - Fax:
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2358
Practice Address - Country:US
Practice Address - Phone:662-843-3654
Practice Address - Fax:662-843-3622
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE7319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist