Provider Demographics
NPI:1619201787
Name:PETRUTIU, ALYCE MARIE
Entity Type:Individual
Prefix:MRS
First Name:ALYCE
Middle Name:MARIE
Last Name:PETRUTIU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 15TH ST
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-2746
Practice Address - Country:US
Practice Address - Phone:831-373-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40190183500000X
NV9309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist