Provider Demographics
NPI:1699116012
Name:REVERON, SAMUEL LUIS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LUIS
Last Name:REVERON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 78TH ST
Mailing Address - Street 2:D5
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5868
Mailing Address - Country:US
Mailing Address - Phone:215-840-2592
Mailing Address - Fax:
Practice Address - Street 1:140 78TH ST
Practice Address - Street 2:D5
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5868
Practice Address - Country:US
Practice Address - Phone:215-840-2592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-14
Last Update Date:2013-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI033842001835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy