=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346420486
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER W SOMERVILLE JR. RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2007
-----------------------------------------------------
Last Update Date | 11/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 343 MEADOW DR
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-694-8868
-----------------------------------------------------
Fax | 716-694-6771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 197 WALTER AVE
-----------------------------------------------------
City | TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14150-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-694-8868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 034602
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------