Provider Demographics
NPI:1811595838
Name:PETTA, BRETT MICHAEL (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:MICHAEL
Last Name:PETTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 SCENIC RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-2269
Mailing Address - Country:US
Mailing Address - Phone:608-712-3898
Mailing Address - Fax:608-935-9076
Practice Address - Street 1:601 E LEFFLER ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-2123
Practice Address - Country:US
Practice Address - Phone:608-935-2365
Practice Address - Fax:608-935-9076
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13426-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist