Provider Demographics
NPI:1295026821
Name:PETERSON, CHARLES JOHN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 FREMONT AVE S # 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2645
Mailing Address - Country:US
Mailing Address - Phone:612-865-7796
Mailing Address - Fax:
Practice Address - Street 1:308 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0343
Practice Address - Country:US
Practice Address - Phone:612-626-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-01
Last Update Date:2011-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program