1699116012 NPI number — DR. SAMUEL LUIS REVERON PHARMD

Table of content: DR. SAMUEL LUIS REVERON PHARMD (NPI 1699116012)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699116012 NPI number — DR. SAMUEL LUIS REVERON PHARMD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
REVERON

Provider First Name:
SAMUEL

Provider Middle Name:
LUIS

Provider Name Prefix Text:
DR.

Provider Name Suffix Text:

Provider Credential Text:
PHARMD

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

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:
1699116012

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/14/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 78TH ST

Provider Second Line Business Mailing Address:
D5

Provider Business Mailing Address City Name:
NORTH BERGEN

Provider Business Mailing Address State Name:
NJ

Provider Business Mailing Address Postal Code:
07047-5868

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
215-840-2592

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 78TH ST

Provider Second Line Business Practice Location Address:
D5

Provider Business Practice Location Address City Name:
NORTH BERGEN

Provider Business Practice Location Address State Name:
NJ

Provider Business Practice Location Address Postal Code:
07047-5868

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
215-840-2592

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
07/14/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 1835P1200X , with the licence number: 28RI03384200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .