Provider Demographics
NPI:1629526553
Name:PETRISIN, KATIE MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MARIE
Last Name:PETRISIN
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 1:177 MIDDLETOWN RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8254
Mailing Address - Country:US
Mailing Address - Phone:304-368-9355
Mailing Address - Fax:304-368-5422
Practice Address - Street 1:177 MIDDLETOWN RD
Practice Address - Street 2:SUITE #2
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8254
Practice Address - Country:US
Practice Address - Phone:304-368-9355
Practice Address - Fax:304-368-5422
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0008090183500000X
PARP449389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist