Healthcare Provider Details

I. General information

NPI: 1053600502
Provider Name (Legal Business Name): MARIO PETRINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARIO PETRINO PHARMD

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4702
US

IV. Provider business mailing address

821 FAIRFIELD DR
BOARDMAN OH
44512-6447
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-2824
  • Fax:
Mailing address:
  • Phone: 330-726-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH03327097-3
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: