Provider Demographics
NPI:1396144200
Name:PETRA PHARMACY SERVICES, INC.
Entity type:Organization
Organization Name:PETRA PHARMACY SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KUTZKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:941-321-8067
Mailing Address - Street 1:426 PAGOSA STREET
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147
Mailing Address - Country:US
Mailing Address - Phone:970-264-4166
Mailing Address - Fax:970-264-3289
Practice Address - Street 1:426 PAGOSA STREET
Practice Address - Street 2:POB 120
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-4166
Practice Address - Fax:970-264-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10000000013336S0011X, 3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy