Provider Demographics
NPI:1962774521
Name:ROBERTSON, MARK B (PHARM-D)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PHARM-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3699 HIWAY 95
Mailing Address - Street 2:STE 100
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-9118
Mailing Address - Country:US
Mailing Address - Phone:928-704-5065
Mailing Address - Fax:928-704-5075
Practice Address - Street 1:3699 HIWAY 95
Practice Address - Street 2:STE 100
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-9118
Practice Address - Country:US
Practice Address - Phone:928-704-5065
Practice Address - Fax:928-704-5075
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14451183500000X
NV12780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist