Provider Demographics
NPI:1275822231
Name:PETERSON, CARISA NICHOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:NICHOLE
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 1:801 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-2635
Mailing Address - Country:US
Mailing Address - Phone:910-897-4141
Mailing Address - Fax:910-897-2240
Practice Address - Street 1:801 S 13TH ST
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-2635
Practice Address - Country:US
Practice Address - Phone:910-897-4141
Practice Address - Fax:910-897-2240
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0515544Medicaid