Provider Demographics
NPI:1578506036
Name:PETRONIS, NIDA M (RPH)
Entity Type:Individual
Prefix:
First Name:NIDA
Middle Name:M
Last Name:PETRONIS
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 1:6613 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-1878
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2205 W 22ND ST
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1203
Practice Address - Country:US
Practice Address - Phone:630-928-0386
Practice Address - Fax:630-928-0398
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist