Provider Demographics
NPI:1669684015
Name:PETRUSKA, NICHOLAS PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:PAUL
Last Name:PETRUSKA
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 1:2987 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:INDUSTRY
Mailing Address - State:PA
Mailing Address - Zip Code:15052-1301
Mailing Address - Country:US
Mailing Address - Phone:724-601-5814
Mailing Address - Fax:
Practice Address - Street 1:302 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TORONTO
Practice Address - State:OH
Practice Address - Zip Code:43964-1510
Practice Address - Country:US
Practice Address - Phone:740-537-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-23877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist