Provider Demographics
NPI:1295917623
Name:SOMERVILLE, JOHN LAUREN (R PH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LAUREN
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4265 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9328
Mailing Address - Country:US
Mailing Address - Phone:315-589-4092
Mailing Address - Fax:
Practice Address - Street 1:4061 ROUTE 104
Practice Address - Street 2:RITE AID # 10856
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9554
Practice Address - Country:US
Practice Address - Phone:315-589-4691
Practice Address - Fax:315-589-4875
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist