Provider Demographics
NPI:1013119940
Name:PETTEWAY, GENE H (RPH)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:H
Last Name:PETTEWAY
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 1:23326 NW 201ST LN
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-7414
Mailing Address - Country:US
Mailing Address - Phone:386-454-2502
Mailing Address - Fax:
Practice Address - Street 1:1080 N W SANTA FE BLVD
Practice Address - Street 2:
Practice Address - City:HIGH SPRNGS
Practice Address - State:FL
Practice Address - Zip Code:32643
Practice Address - Country:US
Practice Address - Phone:386-454-4259
Practice Address - Fax:386-454-7264
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS12313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist