Provider Demographics
NPI:1265094049
Name:ERICKSON, JOHN WALTER V
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:ERICKSON
Suffix:V
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4659
Mailing Address - Country:US
Mailing Address - Phone:928-863-4356
Mailing Address - Fax:
Practice Address - Street 1:865 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2506
Practice Address - Country:US
Practice Address - Phone:603-749-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist