MEDICARE: MRS. LEWANNE F NETTLES RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	046141	NY

General Provider Information

NPI Number	:	1912238031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEWANNE F NETTLES RPH

Provider Business Mailing Address
First Line	:	2937 W KENDALL RD
Second Line	:
City	:	HOLLEY
State	:	NY
Zip	:	14470-9519
Country	:	US
Telephone Number	:	585-750-2312
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 SCOTTSVILLE W HENRIETTA RD
Second Line	:
City	:	WEST HENRIETTA
State	:	NY
Zip	:	14586-9596
Country	:	US
Telephone Number	:	585-334-0140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2010
Last Update Date	:	01/29/2010

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