Provider Demographics
NPI:1801523667
Name:PETTUS, LENA (PHARMD)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:PETTUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 COUNTY ROAD 5120
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-8124
Mailing Address - Country:US
Mailing Address - Phone:573-247-4698
Mailing Address - Fax:
Practice Address - Street 1:1204 E SCENIC RIVERS BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2843
Practice Address - Country:US
Practice Address - Phone:573-729-4091
Practice Address - Fax:573-729-2394
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017011706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist