Provider Demographics
NPI:1063798304
Name:ROBERSON, DIANE ELAINE (PHARMD, BSPS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ELAINE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PHARMD, BSPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3041
Mailing Address - Country:US
Mailing Address - Phone:216-227-0819
Mailing Address - Fax:
Practice Address - Street 1:11701 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3041
Practice Address - Country:US
Practice Address - Phone:216-227-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03328881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist