Provider Demographics
NPI:1972886687
Name:PELLERIN, PHILIPPE AA JR
Entity Type:Individual
Prefix:
First Name:PHILIPPE
Middle Name:AA
Last Name:PELLERIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3135
Mailing Address - Country:US
Mailing Address - Phone:260-482-5428
Mailing Address - Fax:260-484-6355
Practice Address - Street 1:330 W STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3135
Practice Address - Country:US
Practice Address - Phone:260-482-5428
Practice Address - Fax:260-484-6355
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015598A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist