Provider Demographics
NPI:1548583552
Name:FETTERLY, GINA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:FETTERLY
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 1:44 HUNTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1295
Mailing Address - Country:US
Mailing Address - Phone:716-688-3913
Mailing Address - Fax:
Practice Address - Street 1:6363 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5855
Practice Address - Country:US
Practice Address - Phone:716-635-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist