Provider Demographics
NPI:1477841401
Name:PETTIS, BRENDA ZEAGLER (RPH)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ZEAGLER
Last Name:PETTIS
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:PO BOX 2455
Mailing Address - Street 2:134 KATE CIRCLE
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-2455
Mailing Address - Country:US
Mailing Address - Phone:318-396-5560
Mailing Address - Fax:318-651-8727
Practice Address - Street 1:3304 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7308
Practice Address - Country:US
Practice Address - Phone:318-651-9171
Practice Address - Fax:318-651-8727
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist