MEDICARE: MARY P PETRUZZI R.PH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	4064	CT

General Provider Information

NPI Number	:	1356469167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY P PETRUZZI R.PH

Provider Business Mailing Address
First Line	:	78 ELIZABETH ST
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-3411
Country	:	US
Telephone Number	:	860-528-5019
Fax Number	:

Provider Business Practice Location Address
First Line	:	78 ELIZABETH ST
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-3411
Country	:	US
Telephone Number	:	860-528-5019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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