Healthcare Provider Details

I. General information

NPI: 1396144200
Provider Name (Legal Business Name): PETRA PHARMACY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 PAGOSA STREET POB 120
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

426 PAGOSA STREET
PAGOSA SPRINGS CO
81147
US

V. Phone/Fax

Practice location:
  • Phone: 970-264-4166
  • Fax: 970-264-3289
Mailing address:
  • Phone: 970-264-4166
  • Fax: 970-264-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1000000001
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number1000000001
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number1000000001
License Number StateCO

VIII. Authorized Official

Name: MR. JOHN D. KUTZKO
Title or Position: PRESIDENT
Credential: PHARM D.
Phone: 941-321-8067