Provider Demographics
NPI:1639772403
Name:PETRUNYAK, DAVID MICHAEL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:PETRUNYAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-3437
Mailing Address - Country:US
Mailing Address - Phone:276-228-5561
Mailing Address - Fax:
Practice Address - Street 1:1370 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-3437
Practice Address - Country:US
Practice Address - Phone:276-228-5561
Practice Address - Fax:276-228-2476
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist