Provider Demographics
NPI:1851405211
Name:PETTWAY, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 66B
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AL
Mailing Address - Zip Code:36726-9213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:583 4TH AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:AL
Practice Address - Zip Code:36925-2008
Practice Address - Country:US
Practice Address - Phone:205-392-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist