Provider Demographics
NPI:1376845966
Name:PETERSEN, PATRICIA M (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:PETERSEN
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 1:8145 SW BARBUR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2849
Mailing Address - Country:US
Mailing Address - Phone:503-892-4975
Mailing Address - Fax:
Practice Address - Street 1:8145 SW BARBUR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2849
Practice Address - Country:US
Practice Address - Phone:503-892-4975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist