Provider Demographics
NPI:1811219728
Name:REVERE, JOHN JOSEPH JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:REVERE
Suffix:JR
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 1:525 KNOTTER DR
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1100
Mailing Address - Country:US
Mailing Address - Phone:800-895-8427
Mailing Address - Fax:800-896-8427
Practice Address - Street 1:525 KNOTTER DR
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-1100
Practice Address - Country:US
Practice Address - Phone:800-895-8427
Practice Address - Fax:800-896-8427
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0008686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist