Provider Demographics
NPI:1053600502
Name:PETRINO, MARIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:PETRINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:PETRINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:821 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6447
Mailing Address - Country:US
Mailing Address - Phone:330-726-6874
Mailing Address - Fax:
Practice Address - Street 1:307 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4702
Practice Address - Country:US
Practice Address - Phone:330-758-2824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRPH03327097-3183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist