Provider Demographics
NPI:1508151069
Name:PETRICH, RYAN JOSEPH (PHARM D)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:PETRICH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4407
Mailing Address - Country:US
Mailing Address - Phone:952-445-1727
Mailing Address - Fax:952-253-1727
Practice Address - Street 1:1685 17TH AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-4407
Practice Address - Country:US
Practice Address - Phone:952-445-1727
Practice Address - Fax:952-253-1727
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist