Provider Demographics
NPI:1851127294
Name:ROBERTS, SAMANTHA (RPH)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:327 WAGON WHEEL LN
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1539
Mailing Address - Country:US
Mailing Address - Phone:404-576-3692
Mailing Address - Fax:
Practice Address - Street 1:1100 LEJUNE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4537
Practice Address - Country:US
Practice Address - Phone:217-529-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032248183500000X
IL051.306019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist