Provider Demographics
NPI:1104095793
Name:NETTLES, THOMAS R (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:R
Last Name:NETTLES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 W KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-9519
Mailing Address - Country:US
Mailing Address - Phone:585-638-5843
Mailing Address - Fax:
Practice Address - Street 1:3750 MOUNT READ BOULEVARD
Practice Address - Street 2:CVS PHARMACY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616
Practice Address - Country:US
Practice Address - Phone:585-581-5101
Practice Address - Fax:585-581-2646
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist