Provider Demographics
NPI:1902514060
Name:PETKAC, ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PETKAC
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 1:1316 3RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-3716
Mailing Address - Country:US
Mailing Address - Phone:330-242-5195
Mailing Address - Fax:
Practice Address - Street 1:3820 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-6638
Practice Address - Country:US
Practice Address - Phone:605-229-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist