Provider Demographics
NPI:1083672810
Name:PETTY, DOUGLAS GENE (RPH)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:GENE
Last Name:PETTY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 E MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2654
Mailing Address - Country:US
Mailing Address - Phone:660-627-0718
Mailing Address - Fax:
Practice Address - Street 1:500 N BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3214
Practice Address - Country:US
Practice Address - Phone:660-665-7400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist