Provider Demographics
NPI:1295004752
Name:PETRICONE, JOSEPH R JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:R
Last Name:PETRICONE
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 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-5429
Mailing Address - Country:US
Mailing Address - Phone:860-489-5511
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5429
Practice Address - Country:US
Practice Address - Phone:860-489-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist