1790858934 NPI number — LAPERLE'S IGA PHARMACY, INC

Table of content: MARY JESSICA WILSON BS (NPI 1851578959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790858934 NPI number — LAPERLE'S IGA PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAPERLE'S IGA PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790858934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 TROOPER LESLIE LORD MEMORIAL HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLEBROOK
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-237-5033
Provider Business Mailing Address Fax Number:
603-237-5133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 TROOPER LESLIE G LORD MEM HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLEBROOK
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03576-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-237-5033
Provider Business Practice Location Address Fax Number:
603-237-5133
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
DOUG
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISING PHARMACIST
Authorized Official Telephone Number:
603-237-5033

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0690-P , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)