Provider Demographics
NPI:1669704409
Name:PETRIE, BRENDA L (RPH)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:PETRIE
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 1:3830 ROME ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-2401
Mailing Address - Country:US
Mailing Address - Phone:315-298-5361
Mailing Address - Fax:315-298-1090
Practice Address - Street 1:3830 ROME ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-2401
Practice Address - Country:US
Practice Address - Phone:315-298-5361
Practice Address - Fax:315-298-1090
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist