Provider Demographics
NPI:1154628139
Name:PETRIE, NESSA LORAINE (BSC, RPH)
Entity Type:Individual
Prefix:MISS
First Name:NESSA
Middle Name:LORAINE
Last Name:PETRIE
Suffix:
Gender:F
Credentials:BSC, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 E GREENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2003
Mailing Address - Country:US
Mailing Address - Phone:864-224-8873
Mailing Address - Fax:
Practice Address - Street 1:1412 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2003
Practice Address - Country:US
Practice Address - Phone:864-224-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist