Provider Demographics
NPI:1912238031
Name:NETTLES, LEWANNE F (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LEWANNE
Middle Name:F
Last Name:NETTLES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 W KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-9519
Mailing Address - Country:US
Mailing Address - Phone:585-750-2312
Mailing Address - Fax:
Practice Address - Street 1:201 SCOTTSVILLE W HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-9596
Practice Address - Country:US
Practice Address - Phone:585-334-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist