Provider Demographics
NPI:1922283092
Name:PETRILLO, MARY PATRICIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4161
Mailing Address - Country:US
Mailing Address - Phone:810-496-8845
Mailing Address - Fax:810-720-2757
Practice Address - Street 1:2050 S LINDEN ROAD
Practice Address - Street 2:C/O HEALTHPLUS OF MICHIGAN PHARMACY DEPT
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4161
Practice Address - Country:US
Practice Address - Phone:810-496-8845
Practice Address - Fax:810-720-2757
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist