Provider Demographics
NPI:1255928164
Name:PETRUNYAK, STACY A (RPH)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:PETRUNYAK
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 1:945 N MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4165
Mailing Address - Country:US
Mailing Address - Phone:276-783-6995
Mailing Address - Fax:
Practice Address - Street 1:945 N MAIN ST # A
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4165
Practice Address - Country:US
Practice Address - Phone:276-783-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist