Provider Demographics
NPI:1063925865
Name:PETTICREW, TRISHA RENEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRISHA
Middle Name:RENEE
Last Name:PETTICREW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MARIA DR APT 538
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 DIABLO AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-7311
Practice Address - Country:US
Practice Address - Phone:415-898-1905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77807OtherSTATE BOARD OF PHARMACY