Provider Demographics
NPI:1437434933
Name:PETTINGER, MARK J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:PETTINGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1825 JC KELLOG ST
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8782
Mailing Address - Country:US
Mailing Address - Phone:815-991-5716
Mailing Address - Fax:815-991-5716
Practice Address - Street 1:2100 W STATE ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3693
Practice Address - Country:US
Practice Address - Phone:630-262-0970
Practice Address - Fax:630-262-0974
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist