Provider Demographics
NPI:1952627713
Name:HENRY, PETER W (RPH)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:HENRY
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 204
Mailing Address - Street 2:
Mailing Address - City:RAINBOW LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12976-0204
Mailing Address - Country:US
Mailing Address - Phone:518-327-3456
Mailing Address - Fax:
Practice Address - Street 1:2233 STATE ROUTE 86
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-897-2378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist