Provider Demographics
NPI:1932493210
Name:PETRIDES, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:PETRIDES
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 1:210 N CHURCH ST UNIT 3310
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2389
Mailing Address - Country:US
Mailing Address - Phone:740-424-6388
Mailing Address - Fax:
Practice Address - Street 1:1260 UNION ST S
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-5810
Practice Address - Country:US
Practice Address - Phone:704-793-1629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist