Provider Demographics
NPI:1033660477
Name:PETOT, STACY (RPH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PETOT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3243
Mailing Address - Country:US
Mailing Address - Phone:419-787-6710
Mailing Address - Fax:
Practice Address - Street 1:26400 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1967
Practice Address - Country:US
Practice Address - Phone:567-368-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03114984183500000X
MI5302028935183500000X
IN26015646A183500000X
AKPHAP1548183500000X
HI3457183500000X
AZS019573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist