Provider Demographics
NPI:1336437938
Name:PETTEM, ASHOK (BPHARMACY)
Entity type:Individual
Prefix:
First Name:ASHOK
Middle Name:
Last Name:PETTEM
Suffix:
Gender:M
Credentials:BPHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30283 TRIANGLE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622-3125
Mailing Address - Country:US
Mailing Address - Phone:301-472-1825
Mailing Address - Fax:301-472-1867
Practice Address - Street 1:11710 HENRYETTA CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-4189
Practice Address - Country:US
Practice Address - Phone:731-910-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist