Provider Demographics
NPI:1063644953
Name:PETERSEN, MICHELLE L (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:PETERSEN
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 1:735 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97458-1154
Mailing Address - Country:US
Mailing Address - Phone:541-572-5010
Mailing Address - Fax:541-572-5507
Practice Address - Street 1:735 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MYRTLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97458-1154
Practice Address - Country:US
Practice Address - Phone:541-572-5010
Practice Address - Fax:541-572-5507
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0010057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist