Healthcare Provider Details

I. General information

NPI: 1083833545
Provider Name (Legal Business Name): JOHN RICHARD PETRICONE R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 UNION AVE
LACONIA NH
03246-3115
US

IV. Provider business mailing address

99 EASTMAN SHORE RD N
LACONIA NH
03246-1436
US

V. Phone/Fax

Practice location:
  • Phone: 603-528-1700
  • Fax:
Mailing address:
  • Phone: 603-528-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR857
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: