Provider Demographics
NPI:1871877373
Name:PETTA, KENNETH C (RPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:C
Last Name:PETTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 W TWIN CREEKS TRL
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-6702
Mailing Address - Country:US
Mailing Address - Phone:903-842-4209
Mailing Address - Fax:
Practice Address - Street 1:53 W TWIN CREEKS TRL
Practice Address - Street 2:
Practice Address - City:TROUP
Practice Address - State:TX
Practice Address - Zip Code:75789-6702
Practice Address - Country:US
Practice Address - Phone:903-842-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist