Provider Demographics
NPI:1912027822
Name:PETTAWAY, AMY E (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5457 SAN PAULO DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-3356
Mailing Address - Country:US
Mailing Address - Phone:419-476-7914
Mailing Address - Fax:419-531-5946
Practice Address - Street 1:5224 DORR ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-3602
Practice Address - Country:US
Practice Address - Phone:419-531-2115
Practice Address - Fax:419-531-5946
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-14435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist