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General NPI Number Information
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NPI Number | 1477909984
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Entity Type | Individual
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Provider Name | STEPHEN PETRY PHARMD
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Gender | Male
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Dates
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Enumeration Date | 05/13/2016
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 555 S 70TH ST
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City | LINCOLN
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State | NE
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Zip | 68510-2462
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Country | US
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Telephone | 402-219-7143
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Fax |
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Provider Business Mailing Address
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Address Line | 474 GLENDENNING PL
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City | WAUKEGAN
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State | IL
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Zip | 60087-5138
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Country | US
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Telephone | 847-337-8701
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 15043
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051298835
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License Number State | IL
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