Provider Demographics
NPI:1336418904
Name:PETRACCO, GAVAN
Entity type:Individual
Prefix:DR
First Name:GAVAN
Middle Name:
Last Name:PETRACCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 PIKE ST
Mailing Address - Street 2:WALGREENS PHARMACY
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2108
Mailing Address - Country:US
Mailing Address - Phone:724-903-8392
Mailing Address - Fax:206-903-8432
Practice Address - Street 1:222 PIKE ST
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2108
Practice Address - Country:US
Practice Address - Phone:724-903-8392
Practice Address - Fax:206-903-8432
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60039074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist