Provider Demographics
NPI:1811108079
Name:PETSES, ELAINE A (RPH,CDM)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:A
Last Name:PETSES
Suffix:
Gender:F
Credentials:RPH,CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 82ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4110
Mailing Address - Country:US
Mailing Address - Phone:718-490-4620
Mailing Address - Fax:718-492-8669
Practice Address - Street 1:7501 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3301
Practice Address - Country:US
Practice Address - Phone:718-492-4495
Practice Address - Fax:718-492-8669
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist