Provider Demographics
NPI:1376122580
Name:FIPPEN, PETRA A (RPH)
Entity Type:Individual
Prefix:MS
First Name:PETRA
Middle Name:A
Last Name:FIPPEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4390 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-3119
Mailing Address - Country:US
Mailing Address - Phone:317-796-9447
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016924A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist