Provider Demographics
NPI:1750680518
Name:PETSOS, KATHERINE COLVIN (BPHARM)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:COLVIN
Last Name:PETSOS
Suffix:
Gender:F
Credentials:BPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 S SYKES CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3593
Mailing Address - Country:US
Mailing Address - Phone:321-452-5612
Mailing Address - Fax:321-459-2642
Practice Address - Street 1:90 S SYKES CREEK PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3593
Practice Address - Country:US
Practice Address - Phone:321-452-5612
Practice Address - Fax:321-459-2642
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist