Provider Demographics
NPI:1881777381
Name:PETITTO, JOHN
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:PETITTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:516-775-5699
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE ROAD
Practice Address - Street 2:VA MEDICAL CENTER - PHARMACY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026342183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist