Provider Demographics
NPI:1427696467
Name:ROBERTS, ROLAND THAD
Entity type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:THAD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SUTTON DR
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-1603
Mailing Address - Country:US
Mailing Address - Phone:817-296-1557
Mailing Address - Fax:326-356-3259
Practice Address - Street 1:404 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-2706
Practice Address - Country:US
Practice Address - Phone:325-356-5276
Practice Address - Fax:325-356-3259
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist