Provider Demographics
NPI:1629369053
Name:BEVILACQUA, JAMES W (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:W
Last Name:BEVILACQUA
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-0587
Mailing Address - Country:US
Mailing Address - Phone:518-891-2233
Mailing Address - Fax:518-891-7069
Practice Address - Street 1:61 MAIN ST
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1710
Practice Address - Country:US
Practice Address - Phone:518-891-2233
Practice Address - Fax:518-891-7069
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist