Provider Demographics
NPI:1205054335
Name:PETTY, DAVID WILLIAM (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WILLIAM
Last Name:PETTY
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 1:571 GAIL CT
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1209
Mailing Address - Country:US
Mailing Address - Phone:608-835-3629
Mailing Address - Fax:
Practice Address - Street 1:707 S MILLS ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-258-5051
Practice Address - Fax:608-258-6651
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10754-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist