Provider Demographics
NPI:1215279120
Name:PETRUCCI, BRIAN JOSEPH (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:PETRUCCI
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 1:12671 EMERALD COAST PKWY W UNIT 212
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8304
Mailing Address - Country:US
Mailing Address - Phone:850-424-7438
Mailing Address - Fax:850-279-6718
Practice Address - Street 1:12671 EMERALD COAST PKWY W UNIT 212
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8304
Practice Address - Country:US
Practice Address - Phone:850-424-7438
Practice Address - Fax:850-279-6718
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX417961835P1200X
FLPS54305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy