Provider Demographics
NPI:1619226404
Name:PETRATOS, CARYN NIX (R PH)
Entity Type:Individual
Prefix:MRS
First Name:CARYN
Middle Name:NIX
Last Name:PETRATOS
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2038
Mailing Address - Country:US
Mailing Address - Phone:864-859-4015
Mailing Address - Fax:864-859-3396
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2038
Practice Address - Country:US
Practice Address - Phone:864-859-4015
Practice Address - Fax:864-859-3396
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist