Provider Demographics
NPI:1790831915
Name:PETRUSO, JOHN DOMINIC JR (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOMINIC
Last Name:PETRUSO
Suffix:JR
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 1:20704 HILL RD
Mailing Address - Street 2:
Mailing Address - City:SAEGERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:16433-4048
Mailing Address - Country:US
Mailing Address - Phone:814-763-5322
Mailing Address - Fax:814-763-5322
Practice Address - Street 1:1121 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3107
Practice Address - Country:US
Practice Address - Phone:814-333-1910
Practice Address - Fax:814-333-6657
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP037617L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist