Provider Demographics
NPI:1982814281
Name:PETROCHKO, ANN MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:PETROCHKO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CEDAR MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1541
Mailing Address - Country:US
Mailing Address - Phone:570-474-0567
Mailing Address - Fax:
Practice Address - Street 1:175 S WILKES BARRE BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5040
Practice Address - Country:US
Practice Address - Phone:570-821-0808
Practice Address - Fax:570-823-6239
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP035722L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist