Provider Demographics
NPI:1568684512
Name:PETTY, MALENE ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MALENE
Middle Name:ELIZABETH
Last Name:PETTY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3481 W STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4432
Mailing Address - Country:US
Mailing Address - Phone:815-232-4232
Mailing Address - Fax:
Practice Address - Street 1:7219 WALTON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2607
Practice Address - Country:US
Practice Address - Phone:815-399-7195
Practice Address - Fax:815-399-7273
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist