Provider Demographics
NPI:1093324642
Name:PETERSON, ANGELA M (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 ZLATEN DR APT H304
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-2027
Mailing Address - Country:US
Mailing Address - Phone:816-294-5675
Mailing Address - Fax:
Practice Address - Street 1:450 KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-8522
Practice Address - Country:US
Practice Address - Phone:303-532-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0023191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist