Provider Demographics
NPI:1992298855
Name:PETITTO LONG, ANDREA MARY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:MARY
Last Name:PETITTO LONG
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 1:1000 MEADE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-3195
Mailing Address - Country:US
Mailing Address - Phone:570-961-5100
Mailing Address - Fax:570-961-8599
Practice Address - Street 1:1000 MEADE ST STE 104
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-3195
Practice Address - Country:US
Practice Address - Phone:570-961-5100
Practice Address - Fax:570-961-8599
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045847L183500000X
PARN290719L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No163W00000XNursing Service ProvidersRegistered Nurse