Provider Demographics
NPI:1235776303
Name:PETTY, ROYCE ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:ALAN
Last Name:PETTY
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 1:5118 E I 20 SERVICE RD S
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76008-2630
Mailing Address - Country:US
Mailing Address - Phone:817-441-5982
Mailing Address - Fax:
Practice Address - Street 1:5118 E I 20 SERVICE RD S
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76008-2630
Practice Address - Country:US
Practice Address - Phone:817-441-5982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-07
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX359831835C0205X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835C0205XPharmacy Service ProvidersPharmacistCritical Care