Provider Demographics
NPI:1962053181
Name:PETRELLA, NICOLE MARIA (PHARMD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIA
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ANGELA VILLA LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-1766
Mailing Address - Country:US
Mailing Address - Phone:585-749-7177
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-3021
Practice Address - Country:US
Practice Address - Phone:585-275-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066100333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy