Provider Demographics
NPI:1477178614
Name:PETRETTI, CORY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:PETRETTI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GLEN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2942
Mailing Address - Country:US
Mailing Address - Phone:914-879-2157
Mailing Address - Fax:
Practice Address - Street 1:175 BROAD ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4119
Practice Address - Country:US
Practice Address - Phone:518-793-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI064326-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist