Provider Demographics
NPI:1326221839
Name:PETILLO, ANTHONY LOUIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:LOUIS
Last Name:PETILLO
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 1:20 PINE HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2208
Mailing Address - Country:US
Mailing Address - Phone:917-837-4158
Mailing Address - Fax:212-794-7230
Practice Address - Street 1:931 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-5771
Practice Address - Country:US
Practice Address - Phone:212-794-7200
Practice Address - Fax:212-794-7230
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035071-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist