Provider Demographics
NPI:1104129329
Name:PETHTEL, LARRY N (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:N
Last Name:PETHTEL
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 1:218 PARKVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-722-4574
Mailing Address - Fax:304-722-5089
Practice Address - Street 1:1439 MACCORKLE AVE.
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177
Practice Address - Country:US
Practice Address - Phone:304-722-5086
Practice Address - Fax:304-722-5089
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist