Healthcare Provider Details

I. General information

NPI: 1356072193
Provider Name (Legal Business Name): PETRX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30941 AGOURA RD STE 126B
WESTLAKE VILLAGE CA
91361-4673
US

IV. Provider business mailing address

30941 AGOURA RD STE 126B
WESTLAKE VILLAGE CA
91361-4673
US

V. Phone/Fax

Practice location:
  • Phone: 833-571-7387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JACOB KIBBEE
Title or Position: CEO
Credential:
Phone: 833-571-7387