Provider Demographics
NPI:1386913044
Name:PETKOVSEK, BRUCE ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:PETKOVSEK
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 1:3600 KOLBE RD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1654
Mailing Address - Country:US
Mailing Address - Phone:440-960-3420
Mailing Address - Fax:440-960-3908
Practice Address - Street 1:3600 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1654
Practice Address - Country:US
Practice Address - Phone:440-960-3420
Practice Address - Fax:440-960-3908
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03113613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist