=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346521416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESLEY CROCKETT PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2011
-----------------------------------------------------
Last Update Date | 09/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 COURT ST WALGREENS
-----------------------------------------------------
City | LACONIA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03246-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-524-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 COURT ST WALGREENS
-----------------------------------------------------
City | LACONIA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03246-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 3562
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PR5691
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------