Provider Demographics
NPI:1083833545
Name:PETRICONE, JOHN RICHARD (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:PETRICONE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EASTMAN SHORE RD N
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-1436
Mailing Address - Country:US
Mailing Address - Phone:603-528-6012
Mailing Address - Fax:
Practice Address - Street 1:288 UNION AVE
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3115
Practice Address - Country:US
Practice Address - Phone:603-528-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist