Provider Demographics
NPI:1043213770
Name:PETRUZZI, MARK PETER (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:PETER
Last Name:PETRUZZI
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 1:56 SHIPMAN DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURG
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-633-1343
Mailing Address - Fax:
Practice Address - Street 1:78 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3411
Practice Address - Country:US
Practice Address - Phone:860-528-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4633183500000X
CTPCT4633183500000X
MAPH24321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist