Healthcare Provider Details

I. General information

NPI: 1326526062
Provider Name (Legal Business Name): BRYAN ELLIOT PETROW PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 FERRY RD
CHARLOTTE VT
05445-9092
US

IV. Provider business mailing address

1113 ORCHARD RD
CHARLOTTE VT
05445-9674
US

V. Phone/Fax

Practice location:
  • Phone: 802-735-4150
  • Fax: 651-602-3643
Mailing address:
  • Phone: 802-735-4150
  • Fax: 651-602-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033.0124478
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: