Provider Demographics
NPI:1851472708
Name:PETRILLA, RICHARD A (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:PETRILLA
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 1:440 CHATSWORTH LN
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9623
Mailing Address - Country:US
Mailing Address - Phone:330-533-2188
Mailing Address - Fax:330-743-8106
Practice Address - Street 1:790 N GARLAND AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44506-1078
Practice Address - Country:US
Practice Address - Phone:330-743-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03109313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03109310OtherPHARMACIST LICENSE
OH0679172Medicaid
OH3649184OtherNABP
OH3649184OtherNABP