Healthcare Provider Details

I. General information

NPI: 1306065065
Provider Name (Legal Business Name): CHARLES PAUL PETALAS R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S SHORE DR
CTR BARNSTEAD NH
03225-3213
US

IV. Provider business mailing address

136 S SHORE DR
CTR BARNSTEAD NH
03225-3213
US

V. Phone/Fax

Practice location:
  • Phone: 603-776-5707
  • Fax: 603-776-0213
Mailing address:
  • Phone: 603-776-5707
  • Fax: 603-776-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR0497
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: