Provider Demographics
NPI:1275149718
Name:PETERSON, JOHN C (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 ETHAN TER
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-2244
Mailing Address - Country:US
Mailing Address - Phone:608-482-3079
Mailing Address - Fax:
Practice Address - Street 1:1602 HIDDEN HILL DR
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-7970
Practice Address - Country:US
Practice Address - Phone:608-848-5956
Practice Address - Fax:608-848-5956
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist