Provider Demographics
NPI:1558439430
Name:PETRYNA, MICHAEL STANLEY (RPH, MBA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STANLEY
Last Name:PETRYNA
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W MORLATTON RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19518-8741
Mailing Address - Country:US
Mailing Address - Phone:610-385-1474
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC WILLOW GROVE
Practice Address - Street 2:
Practice Address - City:JRB WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090
Practice Address - Country:US
Practice Address - Phone:215-443-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist