Provider Demographics
NPI:1063645893
Name:PETERSON, JON TOR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:TOR
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 1:9983 WADSWORTH PKWY
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4249
Mailing Address - Country:US
Mailing Address - Phone:303-467-7616
Mailing Address - Fax:303-467-5658
Practice Address - Street 1:9983 WADSWORTH PKWY
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-4249
Practice Address - Country:US
Practice Address - Phone:303-467-7616
Practice Address - Fax:303-467-5658
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist