Provider Demographics
NPI:1043816184
Name:PETTUS, JOYAH LANEY
Entity Type:Individual
Prefix:
First Name:JOYAH
Middle Name:LANEY
Last Name:PETTUS
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 1:11784 AL HIGHWAY 157
Mailing Address - Street 2:
Mailing Address - City:VINEMONT
Mailing Address - State:AL
Mailing Address - Zip Code:35179-9005
Mailing Address - Country:US
Mailing Address - Phone:256-775-6085
Mailing Address - Fax:256-736-5984
Practice Address - Street 1:11784 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:VINEMONT
Practice Address - State:AL
Practice Address - Zip Code:35179-9005
Practice Address - Country:US
Practice Address - Phone:256-775-6085
Practice Address - Fax:256-736-5984
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist