Provider Demographics
NPI:1215221791
Name:PETONIAK, PHILLIP (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:PETONIAK
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 1:40 N AMERICA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2225
Mailing Address - Country:US
Mailing Address - Phone:716-675-3784
Mailing Address - Fax:716-675-7777
Practice Address - Street 1:40 N AMERICA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2225
Practice Address - Country:US
Practice Address - Phone:716-675-3784
Practice Address - Fax:716-675-7777
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist