Provider Demographics
NPI:1629383070
Name:PETTY, RON H (RPH)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:H
Last Name:PETTY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 TEXAS AVE S
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-3914
Mailing Address - Country:US
Mailing Address - Phone:979-693-1238
Mailing Address - Fax:979-693-8969
Practice Address - Street 1:1900 TEXAS AVE S
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-3914
Practice Address - Country:US
Practice Address - Phone:979-693-1238
Practice Address - Fax:979-693-8969
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist