Provider Demographics
NPI:1659693919
Name:PETRIK, LEONARD JAMES (PHARM D)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JAMES
Last Name:PETRIK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-2377
Mailing Address - Country:US
Mailing Address - Phone:605-224-1655
Mailing Address - Fax:605-945-2298
Practice Address - Street 1:1615 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-2377
Practice Address - Country:US
Practice Address - Phone:605-224-1655
Practice Address - Fax:605-945-2298
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist