Provider Demographics
NPI:1245789023
Name:PETERSON, STEPHANIE (RPH)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
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 1:9200 W LOOMIS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8887
Mailing Address - Country:US
Mailing Address - Phone:414-529-9275
Mailing Address - Fax:414-529-9222
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8887
Practice Address - Country:US
Practice Address - Phone:414-529-9275
Practice Address - Fax:414-529-9222
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist