Basic Information
Provider Information | |||||||||
NPI: | 1003418385 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | CLYDE | ||||||||
MiddleName: | LLOYD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | III | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROBERTS | ||||||||
OtherFirstName: | CLYDE | ||||||||
OtherMiddleName: | LLOYD | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | III | ||||||||
OtherCredential: | PHARMD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 401 CONSTANT FRIENDSHIP BLVD | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | MD | ||||||||
PostalCode: | 210092566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105699406 | ||||||||
FaxNumber: | 4105694681 | ||||||||
Practice Location | |||||||||
Address1: | 401 CONSTANT FRIENDSHIP BLVD | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | MD | ||||||||
PostalCode: | 210092566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105699406 | ||||||||
FaxNumber: | 4105694681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2020 | ||||||||
LastUpdateDate: | 11/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 15255 | MD | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.