Provider Demographics
NPI:1386962405
Name:ROBERTS, JACQUELINE MARIE (RPH, PHARMD)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 OLD FARMS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-3712
Mailing Address - Country:US
Mailing Address - Phone:860-633-2012
Mailing Address - Fax:
Practice Address - Street 1:67 OLD FARMS RD
Practice Address - Street 2:
Practice Address - City:SOUTH GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-3712
Practice Address - Country:US
Practice Address - Phone:860-633-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008290183500000X
MA23140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist