Provider Demographics
NPI:1316319874
Name:PETROVICH, NICHOLAS MICHAEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:PETROVICH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17248 S DUPONT HWY
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19952-2479
Mailing Address - Country:US
Mailing Address - Phone:302-398-1200
Mailing Address - Fax:302-398-1204
Practice Address - Street 1:17248 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:HARRINGTON
Practice Address - State:DE
Practice Address - Zip Code:19952-2479
Practice Address - Country:US
Practice Address - Phone:302-398-1200
Practice Address - Fax:302-398-1204
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21727183500000X
DEA1-0004439183500000X
PARPI007619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist