Provider Demographics
NPI:1700868494
Name:PETRICH, JOHN JACOB (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:PETRICH
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 1:1319 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-3738
Mailing Address - Country:US
Mailing Address - Phone:864-232-4662
Mailing Address - Fax:864-271-5276
Practice Address - Street 1:1319 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3738
Practice Address - Country:US
Practice Address - Phone:864-232-4662
Practice Address - Fax:864-271-5276
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC726101Medicaid
SCDME458Medicaid
SCDME458Medicaid