Provider Demographics
NPI:1497745038
Name:PETTY, RICHARD W (RPH)
Entity type:Individual
Prefix:MISS
First Name:RICHARD
Middle Name:W
Last Name:PETTY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
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Mailing Address - Street 1:1525 BROADWAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-763-3146
Mailing Address - Fax:320-763-7231
Practice Address - Street 1:1525 BROADWAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-763-3146
Practice Address - Fax:320-763-7231
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN111895-9183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist