Provider Demographics
NPI:1003402017
Name:PETERSON, CARL (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:PETERSON
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 1:200 S 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3965
Mailing Address - Country:US
Mailing Address - Phone:406-586-4785
Mailing Address - Fax:
Practice Address - Street 1:200 S 23RD AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3965
Practice Address - Country:US
Practice Address - Phone:406-586-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-73448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist