Provider Demographics
NPI:1831506963
Name:PETKO, VITALIYA
Entity type:Individual
Prefix:
First Name:VITALIYA
Middle Name:
Last Name:PETKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 GLENWOOD POINTE LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2976
Mailing Address - Country:US
Mailing Address - Phone:505-216-1731
Mailing Address - Fax:
Practice Address - Street 1:2266 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2620
Practice Address - Country:US
Practice Address - Phone:595-323-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist