Provider Demographics
NPI:1073661146
Name:PETERSON, ELIZABETH CLARKE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:CLARKE
Last Name:PETERSON
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 1:1908 SUTTON PLACE TRL
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-6042
Mailing Address - Country:US
Mailing Address - Phone:254-698-2564
Mailing Address - Fax:254-288-8960
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-288-8801
Practice Address - Fax:254-288-8960
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34696183500000X
VA0202007765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist