Provider Demographics
NPI:1902575947
Name:PETITT, MICHAEL CARROLL (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARROLL
Last Name:PETITT
Suffix:
Gender:M
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MYLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4693
Mailing Address - Country:US
Mailing Address - Phone:931-436-4136
Mailing Address - Fax:
Practice Address - Street 1:800 SOUTH JAMES CAMPBELL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-777-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN435501835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care