Provider Demographics
NPI:1003403775
Name:PETTY, NICHOLAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PETTY
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 1:5081 WINTER ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-8213
Mailing Address - Country:US
Mailing Address - Phone:970-685-0407
Mailing Address - Fax:
Practice Address - Street 1:15180 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2742
Practice Address - Country:US
Practice Address - Phone:941-423-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS58943OtherPHARMACIST LICENSE