MEDICARE: GINA PETRUZZO

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	14528	MD

General Provider Information

NPI Number	:	1982009619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA PETRUZZO

Provider Business Mailing Address
First Line	:	11449 NEWPORT BAY DR
Second Line	:
City	:	BERLIN
State	:	MD
Zip	:	21811-9641
Country	:	US
Telephone Number	:	443-373-3528
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 PHILADELPHIA AVE
Second Line	:
City	:	OCEAN CITY
State	:	MD
Zip	:	21842-3650
Country	:	US
Telephone Number	:	410-289-6513
Fax Number	:

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

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	10/23/2014

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