Provider Demographics
NPI:1851663942
Name:PETKUS, MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETKUS
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 1:1272 JANAS LN
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-6123
Mailing Address - Country:US
Mailing Address - Phone:708-846-9798
Mailing Address - Fax:
Practice Address - Street 1:1340 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2750
Practice Address - Country:US
Practice Address - Phone:815-895-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist