Provider Demographics
NPI:1043534761
Name:EMRICH-PETRILLO, NANCY (RPH)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:EMRICH-PETRILLO
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 1:200 SHEFFIELD ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2314
Mailing Address - Country:US
Mailing Address - Phone:908-389-1818
Mailing Address - Fax:877-290-1812
Practice Address - Street 1:200 SHEFFIELD STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2314
Practice Address - Country:US
Practice Address - Phone:908-389-1818
Practice Address - Fax:877-290-1812
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01531500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0211052Medicaid