Provider Demographics
NPI:1417238536
Name:PETRUCCELLI, KIMBERLY B (PHARMD,MBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:PETRUCCELLI
Suffix:
Gender:F
Credentials:PHARMD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 GEDDES ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3717
Mailing Address - Country:US
Mailing Address - Phone:302-652-6757
Mailing Address - Fax:
Practice Address - Street 1:1313 N UNION ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-2533
Practice Address - Country:US
Practice Address - Phone:302-658-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003481183500000X
PARP439708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist