Provider Demographics
NPI:1811635055
Name:PETRIS, PHILIP ROBERT (PHARMD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ROBERT
Last Name:PETRIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63472 2ND STREET LOOP
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-4538
Mailing Address - Country:US
Mailing Address - Phone:503-421-0705
Mailing Address - Fax:
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00157731835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist