Provider Demographics
NPI:1811247901
Name:PETRO, DAVID JOSEPH (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:PETRO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4748 SUSSEX LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5901 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6210
Practice Address - Country:US
Practice Address - Phone:423-855-8035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-15
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist