Healthcare Provider Details

I. General information

NPI: 1134440407
Provider Name (Legal Business Name): STEVEN ROBERT PETRILLO R.PH. REGISTERED PHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SPRINGS RD
BEDFORD MA
01730-1114
US

IV. Provider business mailing address

200 SPRINGS RD
BEDFORD MA
01730-1114
US

V. Phone/Fax

Practice location:
  • Phone: 781-687-2180
  • Fax:
Mailing address:
  • Phone: 781-687-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number3143
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number23960
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: