Provider Demographics
NPI:1154925097
Name:ROBERTS, KRISTIANA DIANNE (RPH)
Entity type:Individual
Prefix:MRS
First Name:KRISTIANA
Middle Name:DIANNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2105
Mailing Address - Country:US
Mailing Address - Phone:765-447-1276
Mailing Address - Fax:765-447-3492
Practice Address - Street 1:1725 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2105
Practice Address - Country:US
Practice Address - Phone:765-447-1276
Practice Address - Fax:765-447-3492
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist