Provider Demographics
NPI:1518143437
Name:LACOURSE, MARTIN (RPH)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:LACOURSE
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 1:55 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOLGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13329-1338
Mailing Address - Country:US
Mailing Address - Phone:315-429-8565
Mailing Address - Fax:
Practice Address - Street 1:55 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DOLGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13329-1338
Practice Address - Country:US
Practice Address - Phone:315-429-8565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036123183500000X
NYI036123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist