Provider Demographics
NPI:1023178738
Name:PETERSON, TIMOTHY LEE (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 BREEZY CT
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 ENTERPRISE DR E
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-2340
Practice Address - Country:US
Practice Address - Phone:952-873-2605
Practice Address - Fax:952-873-6475
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-07-31
Deactivation Date:2011-04-22
Deactivation Code:
Reactivation Date:2015-07-29
Provider Licenses
StateLicense IDTaxonomies
MN116614-7183500000X
IL051.040872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist