Provider Demographics
NPI:1093396004
Name:PETRO, BEDEAR PAUL JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:BEDEAR
Middle Name:PAUL
Last Name:PETRO
Suffix:JR
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 1:2675 ATTALA ROAD 5212
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-6439
Mailing Address - Country:US
Mailing Address - Phone:662-582-3155
Mailing Address - Fax:
Practice Address - Street 1:210 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-389-4332
Practice Address - Fax:601-389-4331
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist