Provider Demographics
NPI:1043422389
Name:PETERSBURG, PAULA KAY (RPH)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:KAY
Last Name:PETERSBURG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 UPPER PRAIRIE DOG RD
Mailing Address - Street 2:
Mailing Address - City:BANNER
Mailing Address - State:WY
Mailing Address - Zip Code:82832-9712
Mailing Address - Country:US
Mailing Address - Phone:307-683-3248
Mailing Address - Fax:
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-672-3473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist