Provider Demographics
NPI:1437383650
Name:FETTY, ROBERT ANTHONY (RPH)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:FETTY
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 1:2612 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-4468
Mailing Address - Country:US
Mailing Address - Phone:330-505-0089
Mailing Address - Fax:330-372-3913
Practice Address - Street 1:2612 SANDALWOOD DR
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-4468
Practice Address - Country:US
Practice Address - Phone:330-505-0089
Practice Address - Fax:330-372-3913
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-17334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist