MEDICARE: DR. MALENE ELIZABETH PETTY PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.290837	IL

General Provider Information

NPI Number	:	1568684512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALENE ELIZABETH PETTY PHARMD

Provider Business Mailing Address
First Line	:	3481 W STEPHENSON ST
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-4432
Country	:	US
Telephone Number	:	815-232-4232
Fax Number	:

Provider Business Practice Location Address
First Line	:	7219 WALTON ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2607
Country	:	US
Telephone Number	:	815-399-7195
Fax Number	:	815-399-7273

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/20/2019

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