Provider Demographics
NPI:1013384908
Name:PETRIE, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HEATHER STONE CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7140
Mailing Address - Country:US
Mailing Address - Phone:774-254-3001
Mailing Address - Fax:
Practice Address - Street 1:620 CONGAREE RD
Practice Address - Street 2:SUITE F
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3502
Practice Address - Country:US
Practice Address - Phone:864-241-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23925183500000X
SC13934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist