Provider Demographics
NPI:1639658941
Name:PETTKO-SELF, LISA MARIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIA
Last Name:PETTKO-SELF
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 1:1012 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5226
Mailing Address - Country:US
Mailing Address - Phone:724-470-8550
Mailing Address - Fax:
Practice Address - Street 1:1996 EWINGS MILL RD
Practice Address - Street 2:
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-3310
Practice Address - Country:US
Practice Address - Phone:412-269-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-038412-L183500000X
PARP038412L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist