Provider Demographics
NPI:1023324043
Name:PETKEVICIENE, LARISA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:PETKEVICIENE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 US 68
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9125
Mailing Address - Country:US
Mailing Address - Phone:606-564-4044
Mailing Address - Fax:
Practice Address - Street 1:1160 U.S 68
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9125
Practice Address - Country:US
Practice Address - Phone:606-564-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist