Provider Demographics
NPI:1427370774
Name:BOMBARD, DAVID STETSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:STETSON
Last Name:BOMBARD
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 1:210 N. BROAD STREET
Mailing Address - Street 2:BOX #184
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-0184
Mailing Address - Country:US
Mailing Address - Phone:315-646-9055
Mailing Address - Fax:
Practice Address - Street 1:25737 US RT 11
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637
Practice Address - Country:US
Practice Address - Phone:315-629-2402
Practice Address - Fax:315-629-4305
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist