Basic Information
| Provider Information | |||||||||
| NPI: | 1053720474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETITT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGHLANDS SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286986282 | ||||||||
| FaxNumber: | 8286986282 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHLANDS SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286986282 | ||||||||
| FaxNumber: | 8286986282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2014 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 11817 | NC | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.