Provider Demographics
NPI:1972781151
Name:PETRUNOFF, CHRISTINE
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:PETRUNOFF
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 1:8543 107TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3620 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5705
Practice Address - Country:US
Practice Address - Phone:516-766-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040786OtherLISCENSE