Provider Demographics
NPI:1144227448
Name:PETERSEN, NICOLE MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PHARMD
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Mailing Address - Street 1:6625 ALAMO AVE
Mailing Address - Street 2:APT 1E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3129
Mailing Address - Country:US
Mailing Address - Phone:314-446-8555
Mailing Address - Fax:314-446-8500
Practice Address - Street 1:8200 N LINDBERGH BLVD
Practice Address - Street 2:SCHNUCKS PHARMACY
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7107
Practice Address - Country:US
Practice Address - Phone:314-921-7345
Practice Address - Fax:314-921-7346
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2003023575183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist